P - 45397Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �,
SITE ADDRESS >� �
THIS APPLICANT [S:
7':�
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAiL
❑ OWNER BJCONTRACTOR
PROPERTY OWNER/ I N�E:
TENANT _ _ _
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSUR.ANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEiNG
SIZE OF [MPROVEMENT
PHONE: �ii7i �' � t i 'J
NAME:
STATE LICENSE # r1(9D
CITY
�
CERT NU
ADllKESS: l% � � '( f7 ? ' � ClTY�
PHONE ,f,�"'T%.%' ` �G FAX l,6�i'— �
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYINEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
f� MAINTENANCE/REPAIR ❑ REMODELING
:. Tn.� r_ i�i7.-i!�(? Infi. _9n a" �,ypr.!' n
ROOFING
NUMBER OF SQUARES ��_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
W[NDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING Cl-IANGE3 &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
� HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
HEIGHT
Permit No.:
Received By: ��`
D��c' c��� _�
�,
STATE�VIN ZIP_
� �p3 , -
STATF�M_�ZIP
._ r�
FT
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDiNG 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)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Bscrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ (.� '[,�., See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ -rj $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for aetermination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( }
$ .'� Make checks aavab(e to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMiT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowtedge 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,�,ll kyoi•�°h e' review and approval of plans. Q
SIGNATURE OF APPLICANT "�'�H" PRINT NAME � p�ror�'►'a-� �1LCbfi{ DATE `� 1l % i 1
APPROVAL INSP�CTOR SIGNATURE