P - 35231Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ��- ..
SITE ADDRESS _
THfS APPLICANT iS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201I
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❑ OWNER �CONTRACTOR
Permit No.: ��-�'� � �,'��.�)�
Received By: , ,��;' ��ji
Date �'� i i� i r� ��.�
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PROPERTY OWNER/ N,�tE: --�> �' �" /�:� .L <<�x� /. ,-
TENANT
ADDRESS: � 3� �' /.".�c- � i�'= ° Sr/L� < CfTY j�1 � ��/- > STATE �y' ��"`LIP J SY� .�
PHONE: � � �; _.:�.:/�: i � % � � �'_ S �i " �. i" � ��
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
NAME: /'=�� .: �.-_ r.��, _ �:�.- ,: -_ �.._�c4{ �; ��( ��'' .�t;'�U'
STATE LICENSE # � : i � .��' ��/ � LEAD CERT NUMBER �/n-> O�� 7' �✓ _ �'f� -
ADDRESS: eT �_-s-/ j G�'� l j'-/'`. C1TY.�', �%�-r !�' STATEh%'�+E.IP_
PHONE �/,� i'C'' : "'�},-� �f FAX /7� "1' %�''!� �' � i' s
�3SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES �
❑ ADDITION ❑ GARAGE/SHED � W[NDOWS
❑ BASEMENT FiNISH � ROOF ❑ DRARJ TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMM[NG POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCE/REPA]R ❑ REMODELING
ROOFING
NUMBER OF SQUARES _� `:
G.ARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
LENGTH WIDTH HEIGHT
❑ HOUSr ONI,Y
�HOUSE & GARAGE
❑ ATTACHED GARAGE
� DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
FT
BASEMENT REMODELING SUI3MIT_
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
ADDITIONS, & PORCHES SUBMIT:
I. Site Plan/Survey showing the exis[ing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WTNDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ i�l.�-`�
$
$ �: �
$ �,
$ t`� ;c
$
$
$
$
�
$ � �. . ,,_�, `.
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payabie to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all work whi�h requires review and approval of plans .
SIGNATURE OF APPLICANT � �
�•�^. .'`-„�'�__.-- PRINTNAME� /'� v;, .. . .� DATE /�'v�l ��
APPROVAL I]JSPECTOR SIGNATURE /