P - 44350Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � "" `7 %Z� ,
SITE ADDRESS S
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTTVE 1-1-2010
[L ADDj�ESS
,!'G 1 �
❑ OWNER '� ]�CONTRACTOR
.: C G� .�. ri 5�i �
ADDRESS: �.�N�-{ D� r I�✓�+� �Qu� (
PHONE:
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{ CITY /��T1�
STATE LICENSE # D' y� / EXP DATE
ADDRESS: Z�f�$1 d�) �^GWG ���./ �'� CITY�
PHONE (� � Z Z7/D -) O% S FAX %6 3-�
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAIvIILY/NEW CONSTRUCTION STORIES
❑ BASEMENT FIIVISH 0 ROOF
�ECK ❑ SIDING
❑ SWIMM
TYPE OF WORK: I❑ NEW HOME CONSTRUCTTON ❑ ADDITION
❑ MAINTENANCFJREPAIR ❑ REMODELtNG
DESCRTBE WORK BEING DONE: S I C�
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFIlVG ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGFS
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
O Vinyl
❑ Aluminum
O Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS OYes ❑No LOCA1'ION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
❑ DRAIN TILE
❑ OTHER
�
Permit No.:
Received By:
Date Rec'd: : ��
STATFf �%'I ► ZIP_
-3I- �I)
��!'" STATFj/��ZIP
�
I�l
�ASEMEN7 REMODELING SUBMIT:
l. Existing Floor Plan
2., Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCfION INCLUDiNG DECKS,
ADDITIONS_ & PORCHES SUBMIT:
1. Site PlanlSurvey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Caiculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
� 1'YPE OF W1NlX)W TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�], ( ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $"/� / OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Suroharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Totai Due
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$5.00 (State Licensed Residentiat Contractors)
$2100 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks aavable to: Citv of Fridlev Attac
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 acGOrdance with the
approved plan in the case of all work 'ch requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME � n. /✓ J�i�tic`� DATE �"" �I r�CJ