P - 41741Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_J�1{,S�
SITE ADDRESS /
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSCJRANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
Permit No
Received B
CITY OF FRIDLEY r�a�'d
EFFECTNE 1-1-2011
YOUR E-MAIL ADDRESS �'4T1���✓ �'`�'�� R`'�-� I�%�^�Sc*}.a. � ccs�..—
�%1' �J�e G� t��e
❑ OWNER �CONTRACTOR
ADDRESS: �(015 %�G�•�.S'��'� e�-� ^!� CITY
PHONE:
ATE ZIP
NAME: Y-o�,�5 "�L. L�S � _
STATE LICENSE # iZ0(O ,3 `f �csi� LEAD CERT NUMBER
ADDRESS: /g Z Z �'�'� ��-c, /rJGJ CiTY p� �j/ ��`i7� STATY� ✓� ZIP S� �� Z
PHONE (ot� Z - 'Z �'j"t - S �j � FAX
SINGLE FAMILY/NEW CONSTRUCTION
�WO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION
f ❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE: i�e -
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
� Vinyl
❑ Aluminum
❑ Other
GARAGE/SHED
❑ SIDING
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
LENGTH
�,HOU5E ONLY
�-IOUSE & GARAGE
�ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
❑ WINDOWS
� DRAIN TILE
❑ OTHER
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. Lis[ of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed proiect.
2. Two sets of construction plans
3. Energy Calculations
FOR W[NDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED__ NUMBER OF W[NDOWS �
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
$
$
� ���
$ i5�
$
$
$
$
$
$ ! Il'/. �.
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 far determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: City of Fridley
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 complete and accurate; that the work will be in
conformance with the ordinances and codes e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a erm' a 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 all w' h r quires review and approval of plan l j
SIGNATURE OF APPLICANT� PRINT NAME �ifr% f��4"f�J DATE i�/�I���
APPROVAL INSPECTOR SIGN URE