P - 43047Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � D I �
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
Permit No.'.
Received By:
CITY OF FRIDLEY Date �e��:� �
EFFECTIVE I-1-2011
YOUR E-MAIL ADDFtES,,s,
� � � , ,� -e L� /� e rv�' s- �-e
❑ OWNER ONTRACTOR
NAME: �� �, �e �� 's• �
ADDRESS: � R M � CITY,
PHONE:
NAME: ��n !' l' %t
ATE ZIP.
STATE LICENSE q� c>O 9� 7� C> LEAD CERT NUMBER
ADDRESS: �� �� ! � � ��L�2C �� CTTY �a� STAT�ZIP SS��o;
PHOlyE �I� � `'��'� �y.3 �v FAX %G� 7 � ��Y^ �5.� �
6'SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
U ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH 0 ROOF
❑ DECK � SIDING
❑ SWIMMING POOL
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
� OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑� A� ITION
❑ MA(NTENANCE/REPAIR �'REMODELING
DESCRIBE WORK BEING DONE: �C �O O
SIZE OF IMPROVEMENT LENGTH WIDTH
C200FING ❑ HOUSE ONLY
NUMBER OF SQUARES � ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
M EXISTING OPENINGS ❑Yes ❑No
j OR FOR NEW OPENMGS-DESCRIBE SIZE OF
OPENING CHANGES &
� TYPE OF WINDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
WINDOWS
f�il
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDiNG DECKS,
ADDIT]ONS. & PORCHES SUBMtT:
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BA ED•ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
'� USING T�IE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $��° 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���
�'
�'
See Back Page for Fee Schedule
6S% 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 pavable to: Citv of Fridlev 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
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of al!j� r�k whic�h requir�; rev�ew a d approval of pl� �,�
SIGNATURE OF APPLICANT .,C�^--° � �6��� PRINT NAME �/'o.�-, �J /�af �.-.,� DATE �D // �f /
APPROVAL INSPECTOR SIGNA