P - 45840Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /U" S / �
SITE ADDRESS b
THIS APPLICANT [S:
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 I-I-2011
Permit No.:
Received By:�
D���i�:�::�::
YOUR E-MAIL ADDRESS Vs vl �'{f'��c tGc ��P�e�r', �� `rf /�.n e��,«
❑ OWNER �fc;UNTRACTOR
ADDRESS: �� r Q�q70'� �l'� CITY
PHONE: (p (� ^ 3 g'�"�r„�
NAME: �%S�OCI
STATE LICENSE #
LEAD CERT NLIMBER
ADDRESS:_ 4'3 %�t ) T� L�jt �f�/ CITY [� t��4
PHONE %�3 �; %� °.��[�1d FAX %(��-'�"�%-,
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 ❑ �A DITION
❑ MAINTENANCE/REPAIR �'REMODELING
DESCRIBE WORK BEING DONE: _ rf ��� �
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �
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 WINDOW TO BE INSTALLED
TH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF'WINDOWS
NUMBER OF WINDOWS
WIDTH HEIGHT
ATE J/Lf•�.FL[P �S�
STATE Gd11�iZIP ;s�v��
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of struc!ural members to be used
FOR NEW CONSTRUCTION tNCLUDING 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 THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
$
$ �
$
$
$
$
$
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 aavable to: Citv of Fridlev
Attach Stioulations
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 p mit 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 al �r1 requires review and approval of pl s. ,
SIGNATURE OF APPLICANT PRfNT NAME �V,f %�/ ��vG��� DATE �C''�� ��
APPROVAL INSPECTOR SIG T RE