P - 39345Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � «
SITE ADDRESS � � � 2-
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
�` 5i 1
❑ OWNER
PROPERTY OWNER/ I NANtE: .I
TENANT ADD�ss
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
STATE
YOUR �-MAIL ADD
� � �� � LE
�CONTRACTOR
M.o�►j'C��ht,�s-!Z�
2 P�� f��,0�u (�
2 U�•—�32z
# 2s�b 3
PHONE ` " ' U
SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION � GARAG
Q BASEMENT FINISH ROOF
❑ DECK � SIDING
u
Permit No.:
Received By�,
Dat��r�ti: �
�
ATE'—��" ZIP
F,AD CERT LJI�BER
� �TTY �i.r{%i� i Id�1�TATE ZIP � , � ,
o r
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR '�REMODELING
DESCRIBE WORK BEING DONE: �7� P l�'Y�' 1� — 2' �%� , Q
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �� ��,�1��''\ ❑ HOUSE & GARAGE
GARAGES � ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
❑ Vinyl � OSoffit
❑ Aluminum .�� ` �5 � Trim
❑ Other � 'l.� ❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
C
FT
BASEMENT REMODELING SUBMIT:
I . 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 seu 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 I
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
Per►nit Fee $ �� y See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ r .0005 x Permit Valuation Minimum $5.00
License Surcharge $ S�7 $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Pazk Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ � Gj � 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 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 applic on for a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the C�a w"` •equires review and approval of plans. G
SIGNATURE OF APPLI�ANT PRINT NAME �A-ti L�%�� S�' � BATE _` '��' ��
APPROVAL INSPECTOjR SIGNAT RE ,,,m E