P - 36745Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � — �_
SITE ADDRESS ��
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
� �h S3? .� �' - � , � ,�1%l't�� � �,� s—':
�31'OWNER ❑CONTRACTQR
Permit No. r� � i � a"�
Received By:
Dat��d�►� G d �
PROPERTY OWNER/ NAME: /,���/Li( %'• C'Lf�,��/�
TENANT ,e,DDRESS: �,�%� � �� S� /v��� CITY /�"/��� ��y STATE�.��LIP
PHONE: %�3 — �X��^ 5���
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
NAME:
STATE LICENSE N-. LEAD CERT NUMBER
ADDRESS: CITY STATE
FAX
PROPERTY TYPE �SINGLE FAMILYMEW CONSTRUCTION S[ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED ❑ WINDOWS
O BASEMENT FINISH f�'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
� SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION C] ADDITION
{�'MAINTENANCE/REPAIR ❑ REMODELiNG
DESCRIBE WORK BEII3G
ROOFING
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
; PROPOSED HEIGHT:
li 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
� 4�lOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
ZIP
FT
BASEMENT REMODELING SUBMIT:
1. Existing Fioor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION (NCLUDING 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 $ 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
$
$ ��
$ . �pGj
$
$
$
$
$
$
$ : ,ni,
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 pa_yable to: City 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 ordinance d codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicati f pe it and wo k' not s rt without a p rmit on site; that the work will be in accordance with the
approved plan in the case k 'c iew pproval of pl � / Q C� lJ
SIGNATURE OF APPLICAN ' a�,. PRINT NAME �/ CG�I��E V�/ �//
APPROVAL INSPECTOR SI T E"