P - 44966Building
Inspections
763-572-3604
763-502-4977 FAX
DATE i/�" 3CJ "�
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:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201I
O OWNER
YOUR E-MA1L ADDRESS
�CONTRACTOR
Permit No.: CJ�1 � V)
Received B � �
Date �' `��N e� � 2Q
�- � �-i �clC � ��1
ADDRESS: / �� �/�I,�,�t/ � CITY
PHONE:
.�s-,�a%, Gt�j�_.
STATE " �' ZIP
STATE LiCENS� # �Z O�o 3 O$� � LEAD CERT NUMBER
ADDRESS: o�� .3/ (o tiv d1-t5�/ 9'� CiTY G-�L�C Oi,Ive/l_- STATE�ZIP J�
aunrir �%f _ 7, � 2 ff.�/..f/A� n ��.
�SHJGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/I�IEW CONSTRUCTION STORIE�
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH .�tOOF ❑ DRAM TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENA�ICE/REPAIR ❑ REMODELING
ROOFING {_
NUMBER OF SQUARES �`i'
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
IDING
❑ Vinyl
❑ Aluminum
❑ Other
( WINDOWS
!, IN EXISTING OPENINGS ❑Yes ❑No
I OR FOR NEW OPENINGS-DESCRIBE SIZE OF
�� OPENING CHANGES &
I TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
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:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR W[NDOWS — PROVIRE U-VF.LUE 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 $ 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
$ "
$ b
$
$
$
$
$
$
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 ( )
Make checks aavable to: Citv of Fridlev Attach
THIS IS AN APPL[CATION 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 f idley and with the Minnesota Construction Codes; that i understand this is not a
permit but only an application for ermi o' not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all o eview and approval of plans„ / �, /,�/, �-�
SIGNATURE OF APPLICANT PRINT NAME / L ��DATE
APPROVAL INSPECTOR S[GNA