P - 42121Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /Q�S///
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 IMPROVEMENT
BOOFWG
P7UMBER OF SQUARES _
GARAGES
FROPOSED SIZE:
PROPOSED HEIGHT:
�IDI G
❑ Vinyl
❑ Aluminum
❑ Other
BUILDIN�
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE ]-1-2011
`�� �-�
Permit No.:
�� - - . : ��7�i�
�.. �-'� 1 ��� �� i
YOUIt E-MAIL ADDRESS �1 / ;/�lC w1 %�/�L�� f�OL.�eQ'h[�?A)tS1'VI-A c'4e yln
i � �
O OWNER �CONTRACTOR
PHONE: i(o3—cS7I ^'��[(o
STATB LICENSE #
Q SINGLE FAMILYlNEW COi3STRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
�,�,�, �TA��i aP ssy3a
CERT NUMBER e�t�T- ,��____
CITY _�Y.CR.Q__STATF�ZIP_$SIQ?
x �SI-4�s- r�4s-
SIZE
STORIES� __
LJ SWIMMING POOL
NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
� DETACHED GARAGE
❑ DRAIN TILE
� OTHER
BASEMENT IZF.MODELING S iRMIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structival members to be use�
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS & PORCI�ES SLn3MIT�
E
❑ Trim 1. Site Plan/Survey showing the existing stsuctu2es
❑ Fascia and proposed project.
2. Two sets of construction plazns
WIND WS 3. Energy Calculations
LV EXISTING OPENINGS �SYes �No L� ATION OF WIND ` � FOR WINDOWS — PROVIDE U-VALLIE AND
C1R FOR.NEW OPENINGS-DESCRIBE SIZE OF �jjZ�►'�n YbCNM9 i I%iN Y1�- MANUFACTURE STICKER ON WIND�OW.
OPENING CHANGES &
TFPE 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)
'3'OTAL JOB VALUATION $ y� �j� _ OCCUPANCY • TYPE
F'ermit Fee
F'lan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
E.msion Control
Fark Fee
Szwer Main Charge
Total Due
■s�r.s.�
��
���'
� �
�.I
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 Detertnined 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 acknowledge that the information above is complete and accurate; that the work will be in
c��nfarmance with the ordinances and codes f the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
p�rmit but only an application f d work is not to start without a permit on site; that the work will be in accordance vvith the
approved plan in the case of ' es review and approval of pl � f�j ���/,,
S=GNATURE OF APPLICANT PRINT NAME ��� �/�DATE /O,��I �l
APPROVAL INSPECTOR STG ruF -.