P - 40834Building BUILDING
Inspections RE'SIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-I-2011
I DATE �1 �I �l� YOUR E-MAIL ADDRESS
�� SITE ADDRESS � i%S L� i / %c� 'Y �bC� �� �/l . � 1r l (�I �E' i �% . �i
THIS APPLICANT IS:
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
SIZE OF [MPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
�OWNER ❑CONTRACTOR
NAME: C, � /�1 t/'��,��!' � /
ADDRESS: �Z �� � �� i j,��� U
PHONE: ��j� ^-� � �' =�
NAME:
STATE LICENSE #
ADDRESS:
PHONE
Permit No.: ��G � � "� ���
Received By:.ri,' ("�
�'�e� �:� � � � �
CiTY i"" j9'c d j��STAT&��ZIP
LEAD CERT NUMBER
CTTY STATE ZIP
FAX
�,SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES_�_
❑ ADDITION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
I] NEW HOME CONSTRUCTION D ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
, ,�J__ _..,_� _. _ L 1 � � i..�
WINDOWS
IN EXISTING OPENINGS Yes ONo
OR FOR NEW OPENINGS-D SCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED `
ALL FEES ARE BASED
TOTAL JOB VALUATION $ '
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS r IC(IiU� �'P �W'�'iU
NUMBER OF WINDOWS
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIOiVS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE ST►CKER ON WINDOW.
VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1 9 U.B.0 FEE SCHEDULE)
�"; � � � � �Q OCCUPANCY TYPE
$ �'�j . Z� 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 ofFridley 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 �ity of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and k is n to start without a permit on site; that the work will be in accordance with the
approved plan in the case of al o�whi requires r ie nd approval of pJans. ���J' �� !/
SIGNATURE OF APPLICANT t PRIj�1T NAME��� r��_�Q�� V' DATE
APPROVAI, INSPECTOR SIGNATURE / ��� � �