P - 47811Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �y� �"
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
�Z3.�2
Permit No.
Received By:
Da���d���p`� � � ���
siTE ADD�ss _ �G a/ S—'� �'t-
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: oN �p�„i
TENANT K, � � cITY
ADDRESS:
PHONE: STATF./�IP-- ��
ELING, IN�.,
CONTRACTOR NAME: �
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # P�n9 ' LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: CITY ST.aTE zir
INSURANCE Du„�,� .
PROPERTY TYPE $SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STOF
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH .B-iZpOF
❑ DECK 9-�IDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
-B'IVIAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �- �
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ,�A ❑ HOUSE ONLY
NUMBER OF SQUARES �_ �% � ❑ HOUSE & GARAGE
GARAGES �� ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
❑ Vi�yl ❑Soffit
❑ Aluminum ❑ Trim
§�j,Other � r �' %0 0 ❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
❑ DRAIN TILE
❑ OTHER
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:
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.
� TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS I
hLL r��� H� tsa�r.L viv vALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�� 1 r(IJ,�I�G THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ d�� nr�� Tp s,.r�� T��,,,,,
�
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � �T% 2 J 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 payable to• Ci of Fridley Attach
THIS IS AN LICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I owledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances a c es e Ci of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for i d o is not to start without a p rmit on site; that the work will be in accordance with the
approved plan in the case of all w ic r ' w and approval of pla . �/
SIGNATURE OF APPLICANT T NAME eN�( LD I�JiU�'r� �0 .- ��-�/
APPROVAL INSPECTOR SIGNATU DATE