P - 47260Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /I'�'I �I{
SITE ADDRESS ��
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 11-2011
YOUR E-MAIL ADDRESS �
❑ OWNER
PHONE: l /� _3 —
NAME: y-p� �
STATE LICENSE # G
ADDRESS: 7� � ,
PHONE (ps' �3 v8�-3� �
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
CITY
SIZE
❑ BASEMENT FINISH vL,J11LU
� ROOF
❑ DECK tfl°SIDING
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ SWIMMING POOL
❑ MAINTENANCE/REPAIR � ADDITION
❑ REMODELING
DESCRIBE WORK BEING DONE: �
_ `
SIZE OF tMPROVEMENT LENGTH
WIDTH
ROOFING � ❑ HOUSE ONLY
NUMBER OF SQUARES I� SS� ❑ HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ¢. ❑ DETACHED GARAGE
PROPOSED HEIGHT: °'�
/
SIDING ' vv�
P� vinyi N Sqb I,SVO
O Aluminum
❑ Other
Permit N
Received By • '
�,�e�v� � � '� ��'��
A
CERT NUMBER EXP:
CITY � STATE�Ip (�
❑ DRAIN TILE
❑ OTHER
nnivn i SQ FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS & PORCHES SUBMIT:
❑ Trim REMOVED? ❑ YES � NO � Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
WINDOWS 2. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ONo LOCAT'ION OF WINDOWS 3 Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROVIDE U-VALUE AND
OPENING CHANGES & MANUFACTURE STTCKER 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
Permit Fee $ - TYPE
�- See Back rage for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ ` � .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft=
Erosion Control $ ft x $25= $
Park Fee $450 Conservation Plan Review
$ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessa
Total Due $ rY i) Non Necessary O
— Make checks pa able to: City of Fridlev err�..ti e«:..,.�...:,.__
THIS IS AN APPLICATION FOR A PERMI"C-NOT VALID UNTIL PROCESSED A^` V V
I hereby apply for a buiiding 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 f a p rmit 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 w r h' equires review and approval of p
S[GNATURE OF APPLICANT � PRINT NAME ���n � ` � � /
APPROVAL INSPECTOR SIGNA �q,�_,,_DATE
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