P - 46603Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_ ! / / �
SITE ADDRESS �L
THIS APPLICANT [S:
PROPERTY OV
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-t-2011
YOUR E-MA1L ADD}tESS _
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� OWNER
PHONE:_ l� �i -"�� g in —Q 6`Gr�
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE #
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS:
INSURANCE pHONE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
I�SINGLE FAMILYINEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH �ROOF
❑ DECK ❑ SIDING
❑ SWIMM
❑ NEW HOME CONSTRUCTION
i� MAINTENANCE/REPAIR
; DESCRIBE WORK BEING DONE:
: C� ( Y' /� �-� O HOUSE ONLY
OF SQUARES � 0 HOUSE & GARAGE
i PROPOSED SIZE:
' PROPOSED HEIGHT:
IDING
❑ Vinyl
❑ Aluminum
❑ Other
CITY
Permit No.:
Received By:,
� . :�� ��.
ATF�ZIP
CERT NUMBER
CITY STATE ZIP
FAX
SIZE� Do p�,.(�'iL�¢
STORIES
?/SHED ❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
NG POOL
❑ ADDITION
❑ REMODELRVG
WiDTH HEIGHT
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
[N EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRlBE SIZE OF
OPENIIVG CHANGES &
F7'
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
���
FOR NEW CONSTRUCTION fNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT.
l. 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 �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ _ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surchazge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Chazge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ �+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ , 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 1 acknowledge that the information above is complete and accurate; that the work will be in
conforma.nce 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 accord nce with the
approved plan in the case of Il rk wh,i�c eyuires review and approval of plans.
SIGNATURE OF APPLICANT ����A.�D� /� _,E� _,.,, op„� PRINT NAME �.T2 �2 �L-2_ IrGI12 i DATE I I
APPROVAL INSPECTOR SiGNdT'(1RE �C