P - 39368Building
Inspections
763-572-3604
763-502-4977 FAX
DATE f _�' � ;'�.
SITE ADDRESS ` f
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
,YOUR
�J�
❑ OWNER �ONTRACTOR
ADDRESS: :�1 ;, �'� '`;
PHONE:_ivl�Z �� Z L' � Cy� � C,-
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STATE LICENSE #
ADDRESS: % `����
PHONE Cr� � Z `
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0� SiNGLE FAMILY - �ii�
❑ TWO FAMILY/NEW CONSTRUCTION
CiTY
Permit No.:� � � � � � C �
�
Received By:
���e~ , ���
�°`���I 'I 7
ATE ZIP
.D CERT NUMBER
CiTY lM �l K� � STATE�/�[ZIP �' � � '� �''
FAX
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
O BASEMENT FINISH �ROOF 0 DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
� MAINTENANCEIREPA] R�
DESCRIBE WORK BEING DONE;
ROOFING ) �
NUMBER OF SQUARES / C1
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED__ __ _
_�
❑ ADDITION
❑ REMODELING
r^ C (;� � i; �%5 +� � ' � � wG �� �E: C � Cr ,"' ��/
—_T J °
�HOUSE ONLY
HOUSE & GARAGE
❑ ATTACHED GARAGE
� DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. 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 T�HE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ �j_ �`� �'� (? „�' OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ °'
$
$
$
$
$
$
$ ' �
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 of Fridley
Attach Stipulations
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 of 1 wor wh' h re uires review and approval of plans. ! r c� .,
SIGNATURE OF APPLICANT � fl ,,=����1���z----�.-- PRINT NAME CC T I`C �� � I��{ I I C' f' tJ j-1iATE � �%
APPROVAL INSPECTOR SIGNATURE