P - 48027�
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE [ 1 " _ �( 7"
SITE ADDRESS _L
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSiJRANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EF'FECTIVE7-1-2010
YOUR E-MAIL ADDRESS
❑ OWNER L�ONTRACTOR
ADDRESS: I
PHnNF.: �
NAME:�l�(;J'I��JL.i"�..✓t d_/
STATE LICENSE #
ADDRESS: :�i�� c5 �st� j
EXP DATE
CITY
PHONF, �S � � �-1 � �I - ua 3 � FAX �p � �' �
I�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
WIDTH HEIGHT
� ��
�
Perniit No.
Received
STATE/%'�tZIP __rj���
.� i
L�:�
AT�IP
FT
BASEMENT REMODELING SUBMIT:
1. Existing Flo6r Plan
2. Proposed floor plan
3. List of structural members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS ��_ , B,� �^�Ey�.� 3. Energy Calculations
IN EXISTING OPENINGS J�Yes ❑No LOCATION OF WINDOWS �-������G ,.,� FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANiJFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED �- NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION
Pernut Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
(USING THE 1997 U.B.0 FEE SCHEDULE)
OCCUPANCY TYPE
$ See Back Page for Fee Schedule
$ 65% of Building Pernut Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � ., Make checks payable to: Ci .ty of Fridle.y Attach
THIS IS AN APPLICA: I^Ir' FCR .4 PER'vIIT-NOT VP LIn LTNTIL ?ROCF,SCF. D
I hereby apply for a building permit and I aclrnowledge 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 permit and 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 �ork hi require� r�view a approval of ns. - /�
SIGNATURE OF APPLICANT �� y ' )'L(, ` NAME � � � 11�� �� �jl %l � DATE �� � ��i"� � [/
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEPARATE PE TS QU D FO PLUMBING, ELECTRICAL AND;MECHANTCAL WdRK