P - 45833Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �p � a--a.-
SITE ADDRESS ^�
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
YOUR E-MAIL ADDRESS
Permit No.f1�
Received By: ��
I�+�ec :
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PROPERTY OWNER/ NAME: �Y'�Q,h� (�e.�~��-��'�
TENANT p,DDRESS: ��i�r���y,lv�jy� �F_�1 ,�;I'Y 'r^y��--� STATF�YIA%ZIP�����
PHONE: % G 3�- �_"'7 �" O G � I
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CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME:_ (f�'� �''��..�-y oL �
STATE LICENSE # '�
ADDRESS:
PHONE % a —
�:SINGLE FAMILY/NEW CONSTRUCT](
❑ TWO FAMILYMEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �OOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �REMODFI.
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT '�
i200FING �
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED_
__ _ __
LENGTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
EAD CERT NUMBER
1Q�._CTTY � STAT�N�Z,IP��
Q
_F.� �G3 y�a-.. �y
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. 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 BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 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
$
$
$
$
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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 pavable to: Citv of Fridlev
Attach Stipulations
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 compiete 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 a cordan with the
approved plan in the case of I work whi re ir eview and approval of p1J���� ^�t�a�_�
SIGNATURE OF APPI,ICANT �_PRINT NAME_ ,�) n ATE ���
APPROVAL INSPECTOR SIGNATURE