P - 39848Building
Inspections
763-572-3604
763-502-4977 FAX
DATF,_;� � �
� � —
S1TE ADDRESS __�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AI�ID CERTIFICATE OF
INSURANCE
BUILDING
RESIDFNTIAL APPLI�ATION
CITY OF FRIDLEY
EFFECTIVE I-I-20i1
YOUR E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
Permit No.: �"� �"U'Vd Y ►
Received By:
D��'�:� , `,� "'I�.
NAME: r,�/,G�Gc �l.��l�= .�
ADDRESS: y% /`O �/�, /C�=- L/ /P'�= �� C1TY �/j/,D L��/ STAT6'��21P
PHONE: �j� ` ��� �- �j � fi'�
NAME:__L_��/`�'' S'/�J/�%� f'���'�'✓."r/1.Z=..0 /�!�" �/V �
STATE LICENSE �i
ADDRESS:�_
PHONE 'y/ �
LEAD CERT
FAX
(y9,�i-�2d°, Cr�TATFr��'�I's
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGElSHED �'"WINDOWS
� BASEMENT FINISH ❑ ROOF O DRA1N T1LE
❑ DECK ❑ SID]NG ❑ OTHER
❑ SW{MMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAR�]TENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMB6R QF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
O Vinyl
Cl Aluminum
q Other
WINDOWS
IN EXISTING OPENINGS �'es ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED_��
6 �%7��
� HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE � ' L \
❑ DETACHED GARAGE � `
. �
OSoffit �� �
❑ Trim
❑ Fascia
LOCA ION OF WINDOWS �
�i� C %l � � f�`�i��" �.
�� NUM$ER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LAB(
(USING T I�1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $_� _`3 C,�'7.�, OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ Y 3 > �S
$
$
$
$
$
$
$
$
$ -,��-.
$ "! 'd r�
FT
i. xi ng Floor Plan
osed floor plan
3. List of structural members to be used
CONSTRUCTION INCLUDiNG DECKS,
f. Site PlaniSurvey showing the existing structures
and proposed project.
� Two sets of construction plans
Energy Calculations
WI DOWS — PROVIDE U-VALUE AND
P. UFACTURE ST(CKER ON WINDOW.
AND MATERIALS:
i'YPE
See Back Page for Fee Schedufe
65% of Building Permit Fee
.001 times the total job valuation
.Q005 x Permit Va{uation Minimum $5.00
$5.00 (State [.icensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC far 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 Stipulations
TNIS IS AN APPLICATION FOR A PERMIT-NOT VALfD UNTIL PROCESSED
[ 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 will be in accordance with the
approved plan in the case of all work which requires review and approval of p{ans.
SIGNATURE OF APPLICANT PRINT NAME DATE
APPROVAL RJSPECTOR SiGNATURE