P - 42846Building
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
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT[VE 1-1-2011
YOUR E-MAIL ADDRESS
�- �-C?�i S 'f r � �YI d C��-I �
❑ OWNER �C,`ONTRACTOR
NAME: Lt' ` V�/��o `?-� � v�.
, �, , �
Permit No.: > >
Received By: 4%�� 1�'" i'
Da�'��� � � ���'�
ADDRESS: �5�� p-T R � S �r � CITY �1'l�llf �_STATE �'hIJ ZIP ��}3Z
PHONE: �P I Z- �S�"E' S1P3�"
NAME:
v-.. ��' LI�G
STATE LICENSE # �LCS�o ,%j ��-[ 2 LEAD CERT NUMBER
ADDRESS:__ 31P � D �►�NN��2 Y�'v'� � CITY Y�(� u STATE 1� ZIP S��'f �'Z
PHON&_�Ol�-'3����j33Z �.�Z`��°�I�`°'f' FAX
PROPERTY TYPE ��INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE 0�DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE: r'e � 1''� �'k
SIZE OF
ROOFING
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
I WINDOWS
i IN EXISTING OPENINGS ❑Yes ❑No
; OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
� TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER
WiDTH
FT
BA�EMENT REMODELMG SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structuros
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
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �S �J' �.�5
$
$
$ '1
$
$
$
$
$
$ � �
TERIALS:
TYPE
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 payable to: City of Fridlev Attach
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 a work whic re uires review and approval of pl n,sr�.,'�„f
SIGNATURE OF APPL[CANT � � PRINT NAME �'�'\ '�' �'�lntii DATE �A ��� � l (
APPROVAL INSPECTOR SIGNAT E