P - 46727Building
Inspections
763-572-3604
763-502-4977 FAX
SITE ADDRESS
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:
; DESCRIBE WORK BEING
i $IZE OF IMPROVEMENT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-I-2011
YOUR E-MAIL ADDRESS
O OWNER ❑CONTRACTOR
NAME: � � �
ADDRESS: � �
PHONE: � 6 3 ^cS�D Z"� L
NAME: %�'I, {'U � Cf � �S
STATE LICENSE #
ADDRESS: � S T I �
Permit No.: �L"v��V'� (P U�
Received By: ��
D(�C�°1�0�--��-5- 9 �11�
�illL�caO ��
CITY STATE�i � ` ZIP
�( �Is ��'fwc�
LEAD CERT NUMBER
,�. S .� T�' CITY G � ���S� STA
PHONE `�o�'�=I si �°'� y 1—g F�
jB SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILYMEW CONSTRUCTION STORIES '
❑ ADDITION ❑ GARAGE/SHED ❑ WiNDOWS
❑ BASEMENT FINISH �d'ROOF ❑ DRATN TILE
❑ DECK ❑ SiDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
F• R� D,C � r �%i�n/()
WiDTH HEIGHT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELTNG SUBMIT:
I NUMBER OF SQUARES � ❑ HOUSE & GARAGE 1. Existing Floor Plan
; GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
i PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structurai members to be used
' PROPOSED HEIGHT
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Pian/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of consuuction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR W[NDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
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 $ OCCUPANCY TYPE
Permit Fee $ �?�.�,� See Back Page for Fee Schedule
Plan Review $ �`� 65% of Building Permit Fee
Fire Surcharge $ .00] times the total job valuation
Surcharge $ �s .0005 x Permit Valuation Minimum $5.00
License Surcharge $ S� $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ �� Make checks payable to: City 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 ork which e ires review and approval of pla /�+' ,�) ` �./ c�^�/�
SIGNATURE OF APPLICANT Aes ����.�. ` PRINT NAME�D/"� M#' C— tO N DATE k �� l
APPROVAL INSPECTOR SIGNATURE
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