P - 35206Building
Inspections
763-572-3604
763-502-4977 FAX
DA�_ l� -� `f `II
SIT'E ADDRESS � j Q �)C�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BIING
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EF'FECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
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❑ OVVNER ,.�ONTRACTOR
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STA'TE LICENS`E� # (�
ADDRESS: g`7 �-� �P ��
PH9� _ 7�P ��%�S' J l.�. w%c'7�,
SIIJGLE FAIvffLY/NEW CONSTRUCTION
0 'TWO FAMILY/NEW CONSTRUCTION
❑ ADDITTON O GARAGFJSHED ,
O BASEMENT FINISH �tOpF �a,A r'
❑ DECK � SIDING
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NUMBER OF SQUARES �¢_ e
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PKOPOSID SIZE:
PROPaSED HEIGHT:
Permit No.:
Received�By:�
Date �e1a'I�: ..� l� �. .
EAD �ERT NUMBER /U '�'T " 02 J " Z�
CITY 'I � STATE�IZIP�
F.� � I � 7�
SIZE
STORIES
❑ WINDOWS
❑ DRAW 7TLE
Q OTf�R
CONSTRUCTION ❑ ADDTI`ION
vCElREpAIIt ❑ REMODELING
�' $�- I,J �. 0../1'"'t—�-'�J
LENGTH WID�
�-�IIOUSE ONLY
❑ HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
�ASEMENT FMODF7 T�r, St1Rr�t1r
1. Existing Floor Plan
2. Aopoaed floor plan
3. List of shvchual membars to be used
3IDING FOR NEW CbNSTRUCTION INCLUDING DECKS,
0 Vinyl ���t ADDITIONS_ � POR •C MIT;
❑ Aluminum ❑ Trim 1. Site Plan/Sutvcy showing the
0 Other ❑ Fascia P!'alp� ��� stcucwres
a� p�oject.
wnvno s 2. Two sets of conshuctian pla�
w 3- �gr c.�a�u�no�
IN EXISTIN(} OP'ENINC3S ❑Yes pNo LOCATION OF WiNDOWS FOR WINDOWS — PROVIDE U-VALI7E AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINUOW.
OPII�RNG CHANGES �
TYPE OF YVINDOW TO BE INSTALLED N[J1viBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS;
(USING THE 1997 U.B.0 FEE SCI�EDULE)
'OTAL JOB VALi1ATTt�N S � . f�P7 .�......,. . �.�> � �_
Pernut Fes
Plan Review
Fire Swcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
� �� �• �� 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 Cormactors)
� $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 ( )
a ... — -• - -
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 pernut and wor 's not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of a1t work hich requires r w and approval of plans.
SIGNATURE OF APPLICANT �r1 PRINf NAME /�O/�y� 4} tl�! DATE %"�g ^t��
APPROVAL INSPECTOR SIGNATURE � �