P - 39635Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � �f-Y'
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTTFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CIT'S� OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
PHONE:
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STATE LICENSE #
R E-MAIL ADDRESS
CITY
Permit No.: 2���^�
Received By:
�t � /
Date Rec'd:� `�
TATE ZIP
sS�� - �c c
LEAD CERT NUMBER
ADDRESS: /Y � Y _S /.>Y�n ¢ � f CITY � �'+"� �� �- STATE/�`,�LZIP $ S,�d ��
PHONE �G �' ��7°3"C�'S' � FAX
�INGLE FAMILY/NEW COIJSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH (�90F ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ADD(TION
❑ MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE:�=
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT[ON INCLUDING DECKS,
❑So�t ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ � lfl�(� �'j 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
$
$ ��
$
$ j�.c�
$
$
$
$
� . �
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 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 Pridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for pe it 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 rk r u' evie�✓ a d approval of plans �./�� ,( �,/ � " �q
SIGNATURE OF APPLICANT PRIN NAME_ ;�7ZHC-- /J-G�l+�,� DATE � O' /'� li
APPROVAL INSPECTOR SIG T \
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