P - 44934Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � � � ` � �
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:
D�SCRIBE WORK BEING
SIZE OF IMPROVEMENT_
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
. r, .
YOUR E-MAIL ADDRESS
U �'1 S �� � L
❑ OWNER �CONTRACTOR
i:�4�� � %c. -QV Z.� �r�
ADDRESS: E�O�Zq Zt�'�lr� 5'�'• �
PHONE:_'�]Cc"� �� �� �Cp
NAME: ��C� �r 1° o Y � v��o. Y�
STATE LICENSE #
t1LLRLJJ.-l\W w• �\WYhVr`C 1V
PH E G�j? '� \ — \ "'�O"3 --
SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
:r i
Pertnit No.: �) �-(1(J� �
Received B�t��
Da���' �l� � .� � � � �'�
^ � CITY F�^ �� �� � STATE ZIP,
�rn er�t S .-�--v� c -
LEAD CERT NUMBER�
-r'-e '� Ilb CITY��i
•AX ��Z ��3 � '
SIZE
STORIES
;D INDOWS
❑ DRAIN TILE
❑ OTHER
❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAfNTENANCE/REPAIR ❑ REMODELING
ROOFING � HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
WIDTH
, Cdrr�
- �y s�- �
r�_STATE ��ZIP
_�3co 5�y3
BASEMENT REMODELING SUBMIT•
I. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
SIDING FOR NEW CONSTRUCTION INCLUDINGDECKS,
❑ Viny! ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum O Trim 1. Site Plan/Survey showing the existing structures
� Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS �� 3. Energy Calculations
IN EXISTING OPENINGS �i'es �No LOCATION OF WINDOWS i► �,,"� FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF 1 K`��� d�— ,� ��•��'�"` i—� 1�eoMpovr• MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED E.. \ NUMBER OF WINDOWS �
ALL FEES ARE BASED ON
COTAL JOB VALUATION $ '
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Controi
Pazk Fee
Sewer Main Chazge
Total Due
VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(US�I �G THE 1997 U.B.0 FEE SCHEDULE)
��� '� OCCUPANCY TYPE
$ {���j�,5 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 Plan Review
$ Fee Determined by Engineering
�$ —�s-�r �_ Agreement necessary ( ) Non Necessary ( )
a 1• 1( � Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowiedge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and c e e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a pe rt a work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o work w review an . pproval of plan
SIGNATURE OF APPLICANT RINT NAME �V�' � �`qc, S DATE ���� ��
APPROVAL INSPECTOR SIGNATURE