P - 44980Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ( � Z `�Cr% t `
SITE ADDRESS M% � � � G
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MA[L
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❑ OWNER ,f!�CONTRACTOR
V�\�4v`.�
ADDRESS: �� u O (� �\�-� E'�l �( a/ CITY
PHONE: "%6� 7�,�i�ZS�
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Permit No.:
Received By: �
I3����e�+°t� �
ATE��ZIP1�L��
STATE LICENSE #°l F� �S 3�(c C'f LEAD CERT NUMBER
ADDRESS: C1TY STATE ZIP
PHONE FaX
PROPERTY TYPE .�SINGLE FAMILY/NEW CONSTRUCTION
__ ❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
OF
SIZE
STORIES
❑ ADDITION � GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH j� ROOF ❑ DRAIN TILE
❑ DECK d SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAlR ,�1 REMODELING
R FING
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:�
PROPOSED HE[GHT: '
SIDING
❑ Vinyl
O Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
� HOUSE ONLY
f�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
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,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Surveyshowing the existing swctures
and proposed project.
2. Two seu of conswction plans
3. Energy Calculations
FOR WINDOWS — 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)
COTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due _
$ ��1 G�
$
$
$
$
$
$
$
$
$
$ �4 D
ANCY TYPE
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
Agreement necessary ( ) Non Necessary ( )
Make checks pa.yable to: Citv of Fridlev 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 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 accordance with the
approved plan in the case of alj work whi�quires eview and approval of plans. ' +� / t
SIGNATURE OF APPLICANT ��./�G'°c� ''I' j%'r PRINT NAME ., AA ,7 I l� C�L� ``
APPROVAL INSPECTOR SIGNATURE . G-- �i✓1 n��