P - 39363Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 1� / � l I
SITE ADDRESS Uf
THIS APPLICANT IS:
�
BUILDING
RESIDENTIAL APPLICATI�N
CITY OF FRIDLEY
EFFECTIVE 1-I-20I I _
YOUR E-MA1L ADDRESS
❑ OWNER �ONTRACTOR
PROPERTY OWNER/ I NAME: �
TENANT qDDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
N�i 1� n
�—la
.� � �I ll •—
NAME:��
STATE LICENSE #
PHONE `� b � f7�
SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
LEAD CERT NUMBER,
CiTY�
FAX �%��-- S�
SIZE
STORIES
0 BASEMENT FINISH �200F ❑ DRAfN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELfNG
DESCRIBE WORK BEING DONE: I�J[,._
SIZE OF IMPROVEMENT
ROOFING �
NUMBER OF SQUARES Z
GARAGES
PROPOSED S1ZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WiNDOW TO BE INSTALLED
��i t�'i�i�
❑ HOUSE ONLY
�-IOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCATION OF WTNDOWS
NUMBER OF WINDOWS
Permit No.:�;� � �%�r,�� L
Received By:i�i t�' I
Date R���� �' � � � � '� ��
'J , ts=�1�'�
STATE � ✓1ZIP_
�
STATE M✓1� ZIP_
� 0�2��
HEIGHT
F'i'
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. 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.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB �ALUATION $ 6Uli� OCCUPANCY TYPE_ __
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chaxge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �` ] Lj See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ ,� ' .0005 x Permit Valuation Minimum $5.00
$ �jQ $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 ( )
$ f � Make checks payable to: City of Fridley Attach
lations
THIS IS AN APPL[�ATION 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 o City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for permi and o is not to start without a permit on site; that the work will be in ccordance with the
approved plan in the case o� wor w h r q es eview and approval of p a s. �� G
SIGNATURE OF APPLiCANT __^ PR1NT NAME� �G. t�L'" DATE