P - 36041Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFEECTIVE 1-1-2011
Permit No.
Received By: -� : I�
Date ���� � � �a o � � �
DATE �` _�� �� YOUR E-MAIL ADDRESS f�cf�r�-� �r,v[��°L�c.�z� ys ,(�r►.�
SITE ADDRESS �t!� �'�'� �t �
THIS APPLICANT IS: L7 OWNER �CCONTRACTOR
PROPERTY OWNER/
TEI�tANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
_-��.-�_—<����-...��fi ��
- � �L 1
. ��• -..
NAME:�
STATE LICENSE #
ADDRESS: ��I �
PHONE (�� [" (! d'Y ^
ATE ZIP
,D CERT NUMBER
CITY (�7EIT,t"1�1B�'�7L. STATE �ZIP��
FAX ��'�
PROPERTY TYPE �§INGLE FAMILY/NEW CONSTRUCTION S[ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAfN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: � I�W HOME CONSTRUCTION ❑ ADDITION
�v1AINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
�� �-
nyl \
❑ Aluminum
❑ Other
WINDOWS
IN EXTSTING 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
❑ Fasc'sa
LOCATION OF WINDOWS
�r ���f��
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION (NCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
L Site Plan/Survey showing the existing swctures
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 BASE�yjON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
��� (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $��C�, FJSa 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
$
$
$
�b
$
$
$
$
$
$ .
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 payable to: City of Fridley Attach
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 applicati r a i an ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o all rk ic eq ' eview and approval of pla}�����' u°'�� '.- ' L�—
SIGNATURE OF APPLICANT PRiNT NAME U ATE
APPROVAL INSPECTOR SIGN