P - 44903Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ^� � /�
SITE ADDRESS _
THIS APPLICANT IS
:, PROPERTY OWNER/
' TEI�TANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR &MAIL ADDRESS `� � �'� � �skar
❑ OWNER �CONTRACTOR
�'. t-F u G v�
Permit No. ��
Received By: �
�.. -__.� - ,� „f :
. � �
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ADDRESS: S��^"C � CITY STATE ZIP
PHONE: �(� � S `( � � O �
NAME: Q SIl Ai CCi�'i S'�u �'- ' 0� ...� i'� e•
STATE LICENSE # O� D U� l���� 1� LEAD CERT NUMBER
ADDRESS: ��� � i Q„> "7'� � UV CITY�O��I �� STATF�Z(P�
PHONE ��iC __� D � Z FAX
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
� MAINTENANCE/REPAIR
DESCRIBE WORK BF,B�SIG DONE:
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ GARAGE/SHED
O ROOF
❑ SIDING
❑ SWIMMMG POOL
S'fi� v�
LENGTH
S[ZE
STORIES
d DRA(N TILE
❑ OTHER
❑ ADDITtON
O REMODELING
0 ows a.. :
❑ HOUSE ONLY
❑ HOUSE & GARAGE
� ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-D SCRIBE SIZE OF
OPENING CHANGES &
`S ��
HEIGHT
FT
BASEMENT REMODELING SUBM(T:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
P
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of conswction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS /// �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $`�„ �C9� 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
$
� �UU
$
$
$
$
$ - -
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Vatuation 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 Fridlev
Attach Stiuulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 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 wilt be in accordance with the
approved plan in the case of all 'c�' re�3 res review and approval of plar� �� � �`�s./�D//
SIGNATURE OF APPLICANT `�' PRINT NAME QZ� CLS�Q 1� DATE /
APPROVAL INSPECTOR SIGNATURE