P - 44911Building
Inspections
763-S72-3604
763-502-4977 FAX
DATE '� "��
SITE ADDRESS �
'THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOliR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
`���iry �", C��
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-201I
�
�WNER
NAME:
ADDRESS:_
PHONE: �
E-MAIL ADDRESS
Pel'lllli NO.: r i� �
Received By:
�;@ ��'� 2 7 2011
A
STATE ?.If;ENSE # / / �/ � LEAD CERT NUMBER � �� � +C / {J
ADDRES3: �`I7y 0%J� %, _ __ CITYj p�(� /Yi�J STA'
PHONE _tPSI � � `� � (�Co � (,� FAX
�3., E FAMIL EW CONSTRUCTION SIZE
❑ TWO FAM /NEW CONSTRUCTION STORIES
C] ADDITION � GARAGE/SHED NDOWS
Q BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
O DECK ❑ SIDING D OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION O ADDITION
� MAINTENANCE/REPAIR ❑ REMODELING
bESCRIBE WORK BEiNG DONE:
SIZE OF IMPROVEMENT
OR OFING
NUMBER OF SQiJARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
❑ HOUSE ONLY
❑ HOUSE & GARAGE
O ATTACHED GARAGE
O DETACHED GARAGE
� .i �% �
BASEMENT REMODELING SUBMIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
Q/
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT•
❑ Vinyl ❑SofFt 1. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim and proposed project.
❑ Other ❑ Fascia a
�-v,./y�,((��Cmeir.lS +. 2. Two sets ofconstruction plans
�0�'VS .� � . �r1c�i-�,`� % irr f/9 - 3. Energy Calculations -
i;d 'cXiSi'rvi� vr£?di?3G�y� ics uPvo iQ�;ti?iGi�i OF 'tYiNLUV'v / �1�� FUR WINDUWS — YROVIDE U-VALUE AND /
OR FOR NEW OPENINGS-'bESCRIBE SIZE OF ���'GKin . .1�� MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES 8t /,(CG�-1 �( �jl.��h7 ►� _//)Gc t p Q'C�''Z
TYPE Ofi WINDOW TO BE INSTALLED NUM ER OF WINDOVJ�
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR MATERIALS:
'/ (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ % y , � �ft') , � _y� __ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire SUrcharge
Surcharge
License Surcharge
SAC Chazge
�Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � %: �'/. Z.s"
$
$
a �()0
$
$
$
$
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$24=$
$450 Conservation P1an Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 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 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 work ', q ires review and approval of pla ,(�
SIGNATURE OF APPLICANT PRINT NAME_ Y' s � DATE_ l'��" l/
APPROVAL INSPECTOR SIGNA RE � �� �n� °
PLEASE NOTE: SEPARATE PE REQ D FOR PLUMBING, ELECTRICAL AND MEGHANICAL WORK