P - 45745Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 1 J V' 1
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
6FFECTNE 1-1-2011
. YOUR E-MAIL ADDRESS
❑ OWNER ❑CONTRACTOR
NAME:
:YL
PermitNo.:�Qi�� �
i� - - - � : . I �.,..
4�
��� ' � �; � �
ADDRESS: �D � � (9 p� /�/� IU�r CITY �/�D G�%� STATE�ZIP y.32.
PHONE: 1, D �
NAME: �1�"I�G� �a�� N6
STATE LICENSE # 2� t� 3oy N� LEAD CERT NtIMBER
ADDRESS: 3�O : Z 4 �_� L�IG. �w CITY t%�lL (O�S�/C STATE�N ZIP S�3o3
PHONE !(D S��G I� S� S FAX
„�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ,�ROOF ❑ DRATN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF [MPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACNED GARAGE
❑ DETACHED GARAGE
HEfGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT[ON fNCLUDiNG DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim l. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
i WINDOWS 3. Energy Calculations
!, IN EXISTING OPENINGS OYes ❑No LOCATION OF WINDOWS FOR W[NDOWS — PROVIDE U-VALUE AND
�� OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CEiANGES &
�' 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 $�r d fl n 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
$
$
$
$
$
$
$
$
$
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 Fridlev Attach
THIS IS AN APPL[CATION 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 applicati n for a p rm�t and work is not to start without a permit on site; t�at the work will be in accordance with the
approved plan in the case of 1 k�j ch re�uires review and approval of plans�.Q��'y��,� /�,/
SIGNATURE OF APPLICANT - "��/ PRINT NAME u( "r "� �i«'//�/ DATE � �� 3'V r��
APPROVAL INSPECTOR SIGNA RE