P - 39997Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � '���' �� �
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MAIL ADDRESS
SITEADDRESS /J � ��ir� ��ry� �,l �
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
1NSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING D(
SIZE OF [MPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
l,�.ir l,
C
ADDRESS: I 3 l �o_Z /�� �`�� r1. � CITY
PHONE: 7 I-3 � 7/ - yy�L-
NAME:
�
Permit No.: [� �' L ( ��
Received By: 1 ' ���'�
D��'�� �� �. � ��i��
ATE ✓� •22IP ss� 3L-
STATE LICENSE #� Z, LEAD CERT NLJMBER
ADDRESS: ��� �3`� ��j�� S( �L � CTTY �"�'L'�C S STATF%'! c/ZIP S s%�°•
PHONE t�`1G 7�� `/ �I � Z- FAX ��� �7��
) -k`�c%
1�NGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY(NEW CONSTRUCTION STORIES !
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OF ❑ DRAIN TILE
❑ DECK ❑ IDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�GIAINTENANCE/REPAIR ❑ REMODELING
.. c c?. l� c'� I–�– c�,.� ct /C �' !�'GY� r f7� �., E: �::�c
WINDOWS
IN EXISTINCi OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ I-10USE ONLY
�OUSE & GARAGE
S�`ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATiON OF WINDOWS
NUMBER QF
_a.c°d �='�rc��
HEIGHT SQ FT
BASEMENT REMODELING SUBMIT:
1. Existing Ftoor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDIT[ONS. & 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 $ 6�-3 �� 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
$
$ ,;a� �;--� --
$ `l
$ �(�i l ,
$
$
$
$
$
$ Ih�t�w��
See Back Page for Fee Schedule
65°to 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 Fridlev 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 application for a permit 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 al or w�jch requires review and approval of plans �. C�}�/ /
SIGNATURE OF APPLICANT (��� I�C— PRiNT NAME ,�� i�' lf /�G Sct� DATE //� �
APPROVAL INSPECTOR SIGNATURE