P - 40238Building BUILDING permit lvo.: "��t( � �I �
Inspections RESIDENTIAL APPLICATION Received By:�i��
763-572-3b04 CITY OF FRIDLEY nate Re �- ��
763-502-4977 FAX EFFECTIVE 1-I-2011 �
DATE_ �"�" •— I�— J� YOUR E-MAIL ADDRESS
SITE ADDRESS S�r�'. E! l G� "� l/l S'f I�-'��
THIS AI'PL[CANT IS: �OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME:
TENANT . ��.._
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PHONE: %� I � �I�?�'I '�C� �� �
NAME:
STATE LICENSE #
CTTY
CERT NU
ADDRESS: CITY
PHONE FAX
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO EAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGE/SHED �dVINDOWS
❑ BASEMENT FIN[SH ❑ ROOF ❑ DRAIN TILE
❑ DBCK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
C] Fascia
LOCATION OF WINDOWS
NUMBER OF
WiDTH HEIGHT
TATE�%ZIP SS ��
ATE ZIP
FT
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING 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)
TOTAL JOB VALUATION $%Q8.�9 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
$ �3 �St�
$
$
$
$
$
$
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 (
$ r%, y. 7 Make checks payable to: Citv of Fridley
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 Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application far a perm-it and is ot to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all w' ' es 'ew and approval of pl s% o
SIGNATURE OF APPLICANT PRINT NAME /r ��O Y�,tc/c%t,�-IDATE �
APPROVAL INSPECTOR SIGNATURE