P - 45212Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � �"l �
S[TE ADDRESS ���
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LTCENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201 �
YOUR E-MAIL ADDi2ESS %�_�� L�_�wt�C�e r(
/� (eA
❑ OWNER
N�t�: U )/,�r� � ( < � S�fi''Q �
ADDRESS: �� '�^ CITY
PHONE: �-[�,��� '— �� ^ � �
Nat�tE: Q I��-1 C�'t,c��' �'Z E'S'� :�d, �(--t`� "'1 `�vl C
STATE LICENSE # a- U� � �EAD CERT NUMBER
ADDRESS: . � W ti• CITY�,1
PHONE C � ^ � � a FAX
(�SfNGL� FAMILY/NEW CONSTRUCTION SIZE C'l S
❑ TWO FAMILY/NEW CONSTRUCTION STORIES_�_
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �"'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDiNG ❑ OTHER
❑ SWIMMING POOL
O NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR U REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES
FROPOSED SIZE:
PROPOSED HEiGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTTNG OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED_ _
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER
HEIGHT
��i��
Permit No.:
Received By:
Date Rec'd: ��'�I ) %%
0
ATE�� �
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FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONS?RUCTIOtd fNCLUDiNG DECKS,
ADDITIONS, & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing sVUCtures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED �N VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.0 FEE SCHEDULE)
COTAL JOB VALUATION �� 7���'-'� "�-7 �� OCCUPANCY TYPE
Permit Fee $ �'� f..�5" See Back Page for Fee Schedule
Plan Review $ 65% of Bnilding Permit Fee
Fire 5urcharge $ " .001 times the total job valuation
Surcharge $ '' ��_ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ �'r EJ � $5.00 (State Licensed Residentia( Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Contro] $ $450 Conservation Plan Review
Park Fee �$ Fee Determined by Engineering
Sewer Main Charge + N� $ ; Agreement necessary () Non Necessary {)
_Total Due _ $` � Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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 City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a - it d 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 w ic uires review and approval of plan �. s�
SIGNATUREOFAPPLICANT � �v. � PRINTNAME 1S��YJ�/_l�� DATE��'/�
APPROVAL INSPECTOR SIGNATURE al '