P - 46949Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_ �% ' 3 ` I �
SITE ADDRESS ��
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:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MAIL ADDRESS
❑ OWNER �J' CONTRACTOR
NAME: �iv�i �' �[� 1,.... fi/++
ADDRESS: CITY
PHONE:
Permit No.: �..� `o���
Received By: �
��e��� � � �' ��i�
ATE ZIP,
NaM�: l. i�- T��-.�.F-,., ( G,-� p�,-.� �..� � rs
STATE LICENSE #� z r7� 3"7 S 1 b LEAD CERT NUMBER
ADDRESS: I �I .� �13 I vrn. '}- �C'� CITY r� �••� �.<-Ist� STATE �'N/LIP S�� �t-(
PHONE
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE: (C°e —
SIZE OF IMPROVEMENT
ROOFING
', NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
[N EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
FAX
SIZE
❑ ARAGE/SHED ❑ WINDOWS
ROOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER
WiI�TH
HEIGHT
FT
BASEMENT REMODELING SUBMIT
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION tNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT•
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR W[NDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ %O(irJ ' OCCUPANCY TYPF,
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� ����_ See Back Page for Fee Schedule
� 65% of Building Permit Fee
$ L CJ .001 times the total job valuation
$ a .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 of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I 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 p it 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 rk ic q'res review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME S�'� ���r�� DATE ��' 3'" ��
APPROVAL INSPECTOR SIGN URF.