P - 47797Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � j 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:
DESCRIBE WORK BEING
SIZE OF fMPRrn�Fnecwrr
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
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YO R E-MAIL ADDRESS � �1��
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❑ OWNER f1N'ru er-rnn
NAME
u, v� v n--� CITY�
PHONE��o � ^ '7 t( (� l '� Gar--
STATE LICENSE # '2:G 2, 'Z S L� � 2j LEAD CERT NUMBE
ADDRESS: 3 a �,,� � �y a.y� L,�. �[-- CITY
PHONE �n � '�% ^ Z � �o � � �-I FAX � ifl '3
� SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION eT�,n„-� —
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
�MAINTENANCE/REPAIR
❑ GARAGE/SHED ❑ WINDOWS
¢�`ROOF ❑ DRAIN TILE
C5 SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
Permit No.:� �� �(l (�'
Received B �
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U � l �� �� � �
STATE_�ZIp 5���2
S� 'LO� C4 % •
��_STATE��p rj�"j'3�y1.�
�-! �� i 1
I ROOFING `""" � HEIGHT SQ FT �Z7 tl C�i
NUMBER OF SQUARES � � HOUSE ONLY
❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
GARAGES ❑ ATTACHED GARAGE �� Existing Floor Plan
PROPOSED SIZE: ❑ DETACHED GARAGE 2 P�oposed floor plan
PROPOSED HEIGHT: 3. List of structural members to be used
SIDING
❑ Vinyl FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Aluminum ❑Softit ADDITIONS & PORCHES SUBMIT:
❑ Other ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
WINDOWS . 2. Two sets of construction plans
IN EXISTING OPENINGS �Yes ONo LOCATION OF WINDOWS 3• Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROVIDE U-VALUE AND
OPENING CHANGES & MANUFACTURE STICKER ON WINDOW.
; TYPE OF WINDOW TO BE INSTALLED
NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $ �USING THE 1997 U.B.0 FEE SCHEDULE)
Permit Fee �. OCCUPANCY �rvv�
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota! Due
$
$
$
$
$
$
$
$
$
$ . fn
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+6 ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks a able to: Cit of Fridle
Attach Sti ulations
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 e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a per 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 work ' es revi app I of plans.
SIGNATURE OF APPLICANT
APPROVAL INSPECTOR SIGNA U E PR(NT NAME �� ,�� �� (�a� DATE ��
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