P - 47960Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_�
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TE1�IANT
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
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
NAME: ///L��
STATE LICENSE #
ADDRESS:�
PHONE ��"'
YOUR E-MAIL ADDRESS
'�--
s,
CITY
Permit No.:�Z�� �'� ��
Received By�
Date Rre�'�: '
A
07 201
LEAD CERT NUMBER
'f�+w. CITY �%���!'� STATE/"[ IP d%
F.aY /Cg, �5`�l.
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES�_
❑ ADDITION ❑ GARAGE/SHED ❑ WI DOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TiLE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADD(TION
�MAINTENANCE/REPAIR ❑ REMODELING
ROOFINC �C�
NUMBER OF SQUARES `'�/ /
GARAGES T—
PROPOSED SIZE:
PROPOSED HEIGHT:
S[DING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
O Trim
�Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
l;C�l[fL`�1
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITiONS. & PORCHES SUBMIT:
1. 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
I Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ��l. `� t�5 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ ��;:� u $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 ( )
$ ��F� ,�- Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 hereby apply for a building permit nd I knowledge that the information above is complete and accurate; that the work will be in
conformance with the ardinances an o f the C' ey and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for t a t to start without a p mit on site; that the work will be in accordance with the
approved plan in the case of all ' �r and approval of pla . ,_ /' ,�0�� //'
SIGNATURE OF APPLICANT '" �`i-RINT NAME ATE (f� b//
APPROVAL INSPECTOR SIGNATURE