P - 47289Building
Inspections
763-572-3604
763-502-4977 FAX
DATE II
SITE ADDRESS � '
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE l-I-2011
r� S i /�C
YOUR E-MAIL ADDFtESS
�CONTRACTOR
Permit No.:
Rece����1�
Date ec'd:
PROPERTY OWNER/ N,atvtE: J �;4tiZ,a.���
n �a ni
TENANT ADDRESS: ,Y'�I W� K`�� S� W�= CITY r%L� /� �e-�J STATE k^'' ZIP .�,.f� �/,%�
PHONE: 7L 1-�J 3'_ ��� / J
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
STATE LICENSE #
ADDRESS:
PHONE
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYINEW CONSTRUCTION
PERMIT TYPE ❑ ADDITION
❑ BASEMENT FIN1SH
❑ DECK
TYPE OF WORK:
❑ GARAGE/SHED
�ROOF
❑ SIDING
❑ SWIMMING POOL
CERT NUM
CITY
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: S�•^'gJ� �� <2 Tc.�roF;- ,�-2��F
SIZE OF IMPROVEMENT
ROOFING
', NUMBER OF SQUARES ��
I GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ 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
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
1�JI1��11:1
ATE ZIP
FT
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of struc!ural members to be used
FOR NEW CONSTRUCTtON 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
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �;� 5
$
$ '�—
$ i
$
$
$
$
$
$
$ In 4, �
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 Residentiai 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 payable 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 of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application fo perm' 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 all o k ic requires review and approval of plans.
SIGNATURE OF APPLICANT PR1NT NAME �J(�bI'yJ ��'%L�OIfE✓ DATE I� � I�
APPROVAL INSPECTOR SIGNATUR