P - 46256Building
Inspections
763-572-3604
763-502-4977 FAX
DATE����
SITE ADDR$SS / �/�G
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 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
ADDRESS: l'Z� ��1[J,��;y'/�q � CITY
PHONE�.�/ f3 � g`i _7c��
Permit No.:
Received By: �% �
Date $�c�,;� �_����(�
Ktl,
STAT6�ZIP.
NAME: Iy/G?7�T�C.^� fK�c�'i!/X' S
STATE LICENSE # C. �Z .7C���� � LEAD CERT NUMBER
ADDRESS:_%` �tj% �G�°`.ld C C!� CITY��/,LJ STATF%�LIPs�53/�
'i�/T/!.�:���C
�f SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
❑ BASEMENT FINTSH
❑ DECK
TYPE OF WORK: O NEW HOME CONSTRUCTION
O MAINTENANCE/REPAIR
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENTNGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
- TYPE OF WINDOW TO BE MSTALLED
1$ ROOF
❑ SIDING
❑ SWIMM
FAX �DiD � t
SIZE �(9 L(
STORIES /
O WINDOWS
O DRAIN TILE
❑ OTHER
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
�E-IOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
HEIGHT
BASEMENT REiI�fODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTtON INCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
i. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WRJDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
' (USIN�HE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATTON $�/ C9C�r 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
� �
.
s
��o
♦
•`
�����
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.00QS 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 pavable to: Citv of Fridlev
Attach
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 c of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applic o for a and or is not t. start without a permit on site; that the work will be in accordance with the
approved plan in the case f work hi re iew and approval of ptahs. ��_�/ /�
SIGNATURE OF APPLICAN PRINT NAME ��A��i Q(.[�L�J�. DATE CO r�3� �(
APPROVAL INSPECTOR SIGN TURE