P - 41734Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�+'��
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
Q OWNER �CONTRACTOR
ADDRESS: �,� �/� f.c1 ,�F'L{J�j� p,;�� CITY
PHONE: �' `7��3 �S %�° �S� Y
`S� 7 y
Pet�nit No.: �U
Received By: � f
���� � � ����
ATFI���IP,�S�/,� �
STATE LICENSE # O(O/(�j� �Y� LEAD CERT NUMBER /iC%�T- c�,� 7/�- /
ADDRESS:�%/ �'�/Gt ,,s,�i�e,e� CITYJ'�' •�t�/ STAT�i�ip .S�sio7
PHONE �� I" 7DS'"Ll�Q•S� FAX IvS/- S'C'?..�' _ J% y.S-
� SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STOF
17 ADDITION ❑ GARAGE/SHED
� BASE:v:ENT ; I;�'ISH � R^vGi
❑ DECK ❑ SIDING
❑ SWIMMING POI
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDTTION
�,T MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE:�,�,(J/�p y(,�/�RplOttJS L�u �!
r
��IZE OF TMPROVEMENT LENGTH R'IDTH
ROOFING ❑ HOUSE ONLY
P7iJMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGES
F'ROPOSED SIZE:
YROPOSED HEIGHT:
sID[rrc
� Vinyl
❑ Aluminum
❑ Other
� ATTACHED GARAGE
❑ DETACH6D GARAGE
I� DrcAr,v ri�r.
❑ OTHER
BASEMENT REMODELING SUBMIT
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING L�ECKS,
❑Soffit ADDITIONS & POR HES SUBMiT
❑ Trim 1. Site Plan/Survey showing the existing structu;es
❑ Fascia and proposed project.
2. Two sets of construction plan�s
WINDOWS 3. Energy Calculations
LV EXISTING OPENINGS �Yes ❑No LOC T10N F WINDOWS FOR WINDOWS - PROVIDE U-VALL9E AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF / pGr� {!(J(!,G! MANUFACTiJRE STICI{ER ON WINU'OW.
UPENING CHANGES &
TY"PE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING TAE 1997 U.B.0 FEE SCHEDULE)
'TOTAL JOB VALUATION $ �O'i .�S __ OCCUPANCY TY�F,
F'ermit Fee
Flan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Emsion Control
Park Fee
Sewer Main Charge
Total Due
$ f�j �'1 '�„� See Back Page for Fee Schedule
$ 65°r� of Suiiciing 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 DeYermined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ :' � Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowIedge that the information above is complete and accurate; that the w�ork v✓ill be in
G�nfar�nance with the ordinances and codes of the City of Fridley and with the Minnesota Constr�ction Codes; that I understand this is not a
p�rmit but oniy an application for a it d rk is not to st rt without a permit on site; that the work will be in accordance with the
approved plan in the case of all ic iew an pprova f pla s / �/ /� n
S=GNATUREOFAPPLICANT PRINT�E �j%iI�{ N/CKis1/¢•i(. DATE �y/�/�� i
Ai'PROVAL INSPECTOR SIGNA F. � !L � _ ._ .