P - 39845Building
Inspections
763-572-3604
763-502-4977 FAX
DATE��
SITE ADDRESS ^
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE ]-1-2011
. ._ i .. m V .., ,.
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YOUR E-MAIL ADDRESS
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PROPERTY OWNER/ Na�tE:_�7 �j1�
TENANT pDDRESS: I 5 C� C� D�� ri e.
PHONE: �� J Z- � "i � Z ° �J ���
CONTRACTOR
SUBMIT A COPY OF
YOCJR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
v
CITY
NaME: ' +�C i} r ! li
STATE LICENSE # LEACD CERT NC(MBEP
ADDRESS: �j ( � � 1 YYt �[?' ✓ � � - �OX �J � _I CITY�
PHONE (�� I_� Z°I —��- z-t Z F� (� �� I � t
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYINEW CONSTRUCTION STORIES �
❑ ADDI7'ION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK O SIDING O OTHER
❑ SWIMMiNG POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
1�IAINTENANCE/REPAIR ❑ REMODELING
ROOFING ✓(
NUMBER OF SQUARES _1. (
GARAGES
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 WtNDOW TO BE INSTALLED
��:{OUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF W[NDOWS
NUMBER OF
HEIGHT
Permit No.: 1— d �
Received By: �
Date Rec'd: �� �
_STATE M�IP �5 y
� I � STATE�ZIP 'r�'
_ 1i��1
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BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of sVuctu�al members to be used
FOR NEW CONSTRUCTION [NCLUDING 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 WINDOWS — PROVIDE U-VALUS AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
I SAC Charge
Curb Cut Escrow
� Erosion Control
i Park Fee
Sewer Main Charge
' Total Due
$
$ �
$
$ S "�
$
$
$
$
$
$ ��—
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 pavable to: Citv o1' Fridlev Attach
ulations
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 ity of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and w k is to start without a permit on site; that the work will be in accordance with the
approved plan in the case of a o whi re i es e' w and a proval of plans
SIGNATURE OF APPLICANT AME DATE �
APPROVAL [NSPECTOR SI RE
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