P - 48375B�ilding
In��ections
763�572-3604
763-502-4977 FAX
DATE �y � � ' (
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 1-1-2011
L ADDRESS
❑ OWNER ❑CONTRACTOR
Permit No.: -�� � f- t;� L��S
Received By: -
��� �;�Q` �i ���
NAME: %()//l/( �C�L U
ADDRESS: �� Q �%%�iQ L,�-l�� CITY / Q/ %�,/r�i STATE ��ZIP
PHONE: �i�' 73 � & �% �O
NAME: � F'fUC k �. (IL! � L� /� � i'V iN
STATE LiCENSE # ���p ,j � g 4�O LEAD CERT NUMBER
ADDRESS: �%%O�T -�Otife � 5� Q�(. • CITY �-/�(/� �,�lCG' STATE Kr ZIP >i � l�
PHONE � S' I %�G � O�o G FAX
❑ SINGLE FAMILYMEW CONSTRUCTION
�'TWO FAMILYMEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
❑ ROOF
❑ SIDING `
❑ SWIMMING POOL
SIZE
STORIES .
❑ ADDITION
`�T REMODELING
❑ DRAM TILE
❑ OTHER
DESCRIBE WORK BE1NG DONE: ��!R�-cj �f/IW�O��
SIZE OF [MPROVEMENT � G`�/ 1�P LENGTH WIDTH HEIGHT SQ FT
ROOFING
; NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ON[,Y
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. l,ist of structural members to be used
FOR NEW CONSTRUCTION MCLUDING DECKS,
ADDITIONS. & 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-VAI.UE AND
MANUFACTURE STICKER ON WINDOW.
_ __- -- -- - __ . —
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE �,997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ ���� m''� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ ,
$ fl
$
$
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 (
$ r� ,7�i Make checks payable to: City of Fridley
Attach Stipulations
THIS IS AN APP [CATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pe d t ac wledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances an co es of e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application fo a pe 't d 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 ` ires review and approval of pla /�� �J/-'
SIGNATURE OF APPLICANT PRINT NAME �ryriC�/f`� //"/d���TE `� 7-�/
APPROVAL INSPECTOR SIG URE .ir _. �
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