P - 39355Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �'f I Z
SITE ADDRE�S �
THIS APPLICANT IS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-i-2011
YOUR E-MAIL ADDRESS
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�OWNER ❑CONTRACTOR T
Permit No.:20� % (�(?CoC�
Received By:
Date Rec'd: /
PROPERTY OWNER/ N,a�vtE: �,��--` "'��'�'�( ' ��-I (�
TENANT p,DDRESS: b��j?j �`�j ,/J� CITY .�/(� tQ� STATE�ZIP_
PHONE: I(1 f`� ��'�r �!/ ' 3�7 ��_
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
NAME:
STATE LICENSE #
PHONE
f�SINGLE FAMILY/NEW CONSTRUCTION
f� TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED
❑ BASEMENT FINiSH �ROOF
❑ DECK ❑ SIDiNG
❑ SW1MMfNG POOL
LEAD CERT NUMBER.
CTTY
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAfN TILE
0 OTHER
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
I�MAINTENANCE/REPAIR ❑ REMODELING
DESCRTBE WORK BEING
SIZE OF [MPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ Aluminum
� Other
WINDOWS
1N EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
LENGTH � WiDTH HEIGHT
❑ HOUSE ONLY
I,�`HOUSE & GARAGE
/"
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
ATE ZIP
F"i'
BASEMENT REMODELING SUBMIT:
I. Exis[ing Floor Plan
2. Proposed Floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHE3 SUBMIT:
I. 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.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USIN THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ �(�%/ � OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chaxge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota! Due
$ Gf?. :l S
$
$ r
$ .
$
$
$
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 navable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 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 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 case of all wor h' h require r�e and approval of plans. I� /,. f II
SIGNATURE OF APPLICANT LL�s�l�� � PRINT NAME ��L�IA ��j 1/�✓� t� �1 DATE ��` ^ I
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