P - 42844Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� ��!' iZD
SITE ADDRESS !� J � /
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 [MPROVEMENT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
E-MAIL ADDFtESS
+� lSun�N �rwl��
O OWNER �CONTRACTOR
NAIvtE:� 1 G N�'ClFJ" d� G.9 ��5 �
ADDRESS: �e� %% V A N I3 U n fE N CITY
PHONE:_�/ a �� �" '/ 33
NAME: F/bM L
STATE LICENSE #
��
� M Pna�C•� cti r sN� P
G W�'I 4%�O LEAD CERT NUM
S R(IM. R�IJC� x%%� CITY
�.`rI
�,$INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
FAX iS a 7l "
SIZE
STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �.ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION O ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
�E �v �
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
ISDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
�iOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
� Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE iNSTALLED NUMBER OF �
Permit No.:' --� �
Received By: -
Date �� � � `� �, � �
�L,+ G�iM
STATE�ZIP SS y go2
NG / GN STAT
�g3—'7/3
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structurat members to be used
37
FOR NEW CONSTRUCTION INCLUDING 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 WMDOWS – 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'� �a 3� 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
�_
� i�
��i
See Back Page for Fee Schedule
65% of Building Permit Fee
.00I 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 payable to: City of Fridlev
Attach Stipulations
THIS [S 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 tlie ordinances and codes o the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a it an r is ot to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all w � ew and approval of pla nA
SIGNATURE OF APPLICANT PR T NAME ������� Z!L f�l% DATE_ �¢ "�I%— Oc(/ % I
APPROVAL INSPECTOR SIGNAT i