P - 35796�F
B��i%�g
Inspections
763-572-3604
763-502-4977 FAX
DATE � � � ' (
SITE ADDRESS
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:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20ll
YOUR E-MAIL ADDRESS
I I D f' � i'Yl G� �t, Y ��
❑ OWNER �ONTRACTOR
NAME: 1 )(A UPr !'fYl'i
ADDRESS: ��D .,�i Iuf �v'� �I�
PHnNF 1I0� ' �� Z .�1 OI�LI'
NAME: �I I U I
STATE LICENSE �t
ADDRESS:�Q�
.��.�... ,
ST
CERT
Permit No.:0�4 � I�o 1 t�
Received By.
Date k'eb'� � � �- Q � � �
A
ci-rY���.►y�Ti sTA
'��1 � %i�� ��Gl �- �
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH `�ROOF ❑ DRAIN TILE
❑ DECK � SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:��
SIZE OF IMPROVEMENT
NUMBER OF SQUARES �`"'
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
� HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
[7 Fascia
LOCATION OF WINDOWS
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDIi'IONS. & PORCHES SUBMi7':
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR V�'INDOWS — PROVIDE U-VALUE AND
MANUFACNRE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $', D I�a,IN� �HE 1997 U.B.0 FEE SCHEDULE)
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
$ �`I �� �j See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ _.001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ 0 u $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft + 6 ft= ft x$25= $
$ $450 Conservation P(an Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ ��'�,L(D Make checks payable to: City of Fridley At�ach
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 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 �(k�'h�ch e uir v'�ew and approva! of pja��, �1n /�� ,�p,� ����—,(
SIGNATURE OF APPLICANT���II � � v PRINT NAME 1'�GfY l a�� V�� Da�
APPROVAL INSPECTOR SIGNA 1
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK