P - 39622Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � / `
SITE ADDR�ESS ,
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-201I
YOU E-MAIL ADDRESS a s� r�
� 4�1U � � /��I .' . �. �rie
❑ OWNER �CONTRACTOR
NAME: CV Ir � Y1 G v�' �
ADDRESS;
PHONE: � Cv % �j �$ 0 �j S^�
NAME: .��c.1 Sot �' S Gm n S fir��
CITY
�
Permit No.:i'_
Received By:
�
Date Rec'd:
o � GQ ^�- � ,�-� �
ATE ZIP
STATE LICENSE # (ri .� 3 8 LEAD CERT NUMBER
ADDRESS: (� G 3 �r'7'�.� a `�J Q CITY � Oc� STATE_�LIPcS� ���
PHONE � S�" pZ / S"— °�I Z v / FAX
❑ SINGLE FAMILY/NEW CONSTRUCTII
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINiSH
❑ DECK
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION
� MAINTENANCE/REPAIR
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
ROOFING
NUMBER OF SQUARES,�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aiuminum
❑ Other
WINDOWS
IN EXISTING OPENINGS OYes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZB OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED_
SIZE
STORIES
❑ GARAGE/SHED ❑ WINDOWS
�ROOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
C7 SWIMMiNG POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCATION OF WINDOWS
OF WINDOWS
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structurat members to be used
FOR NEW CONSTRUCTION (NCLUDING DECKS,
ADDITIONS_ & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
AL�, FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATIOAT $ 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 _
�(l2� -
$
$
$ fj
$
$
$
$
$
$
$ 02 � I
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 (P(ans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks aavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the i of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f a ermit and is not to start without a permit on site; that the work will be in cordance with the
approved plan in the e iew and approval of pla s. j� I_ C'
SIGNATURE OF APPLICANT PRINT NAME �`�l �t�v YJ QV'7� �ATE � �7 '
APPROVAL INSPECTOR SIG