P - 47338Building
Inspections
763-572-3604
763-502-4977 FAX
DATE��lf�
SITE ADDRESS �S'!
THIS APPLICANT IS:
rxvY1�.K 1 Y V WNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
BUILDING
RESIDENTIAL APFLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
E-MAIL ADDRESS
�CONTRACTOR
a�8��
Permit No.:�(j (�
Received By:
Date Rec'd:
PHONE: "]d, � �:SOai - /6 �"j
TATE��IJ��ZIp ss�3a
STATE LICENSE #_�'%���J�j,� LEAD CERT NUMBER�jt� T' p? 7�A �
ADDRESS:_��%/ �i� o� CITYs�,/ STATE�ZIP�Sl07
PHONE I- 9d. -D/D'S- FAX �S/ �/!15 / 7�/S�
I�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION S�rnurcc
PERMIT TYPE ❑ ADDITION ❑ Ga�GEis�D
O BASEMENT FINTSH ❑ gnnp
❑ DECK ❑ SIDING
❑ SWIMMINGPOOL
TrYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
'�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �
SI2E OF IMPROVEMENT LENGTH �ii g
BOOFING ❑ HOUSE ONLY
PJTJMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGES
FROPOSED SIZE:
F'ROPOSED HEIGHT:
SIDING
0 Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
❑ Fascia
n nn a pw� ;-.TLE
❑ OTHER
HEIGHT
BASEMENT REMODELING SUBMI7�
1. Existing Floor Plan
2. Proposed flooe plan
3. List of structu�al members to be use�
FOR NEW CONSTRUCTION INCLUIDING L�ECKS,
ADDITIONS & PORCHES SUBMIT
1. Site Plan/Survey showing theexisting structures
and proposed project.
WINDOWS 2. Two sets of canstruction plam
LV EXISTING OPENINGS Yes ❑No LOCATION OF WINDOWS 3 Energy Calculations
OR FOR NEW OPENINGS- ESCRIBE SIZE OF FOR WINDOWS - PROVIDE U-VALUIE AND
UPENING CHANGES & MANUFACTURE STICKER ON WINPsOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
USING THE 1997 U.B.0 FEE SCHEDULE)
'�'OTAL JOB VALUATION $ /�/', 6 OCCUPANCY TVPF
� Fermrt Fee
F'ian iceview
Fia�e Surcharge
Surcharge
L,icense Surcharge
SAC Charge
Gurb Cut Escrow
E.rosion Control
I'ark Fee
Sewer Main Charge
Totat Due
$
$ lh.[��
$
$ S[7"�
$
$
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 pa�able to: City of Fridley Attach
TffiS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED . v`V
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
c,�nformance with the ordinances and codes of he City of Fridley and with the Minnesota Construction Codes; that I understaud this is not a
psrmit but only an applicati for a permi d or is not to start without a permit on site; that the work will be in accordance tivith the
a�proved plan in the case of al ork w i e i s ev roval of la ; �`
S=GNATURE OF APPLICANT P p T NAME p�� N�kI 1�! DATE (! �I �
APPROVAL INSPECTOR SIGNATU �.
.. . .
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