P - 46258Building
Inspections
763-572-3604
763-5�02-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:
Received By: { �
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DATE ��=Z 3 C� d l/ YOUR E-MAIL ADDI2ESS /Up p✓���L��`-t �'2,?sf��,,�c��� LO��
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TH[S APPLICANT IS: O OWNER LtPEONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SU$MIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURAAICE
PROPERTY TYPE
PERMIT TYPE
NAME:
ADDRESS: CiTY
PHONE:
STATE LICENSE �
EAD CERT_NUMBER
ATE Z[P
ADDRESS: �7��? ZGr'f�` r7� �(/!�/ CITY %f/DGUTi�!✓t STATE�21P.
PHONE /�/ 7' 3� �%' OO LI S� FAX
�INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE: f f CC r
ROOFING
NUMBER OF SQUARES � �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ �rARAGE/SHED
CsYROOF
❑ SIDING
❑ SWIMMING POOL
SIZE
STORIES �
❑ ADDITION
❑ REMODELING
❑ �IOUSE ONLY
[B'HOUSE & GARAGE
❑ ATTACHED GARAGE
��TACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
M EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WiNDOW TO BE INSTALLED NUMBER OF V
� DRAIN TILE
� OTHER
BASEMENT REMODELING SUBMIT:
I . Existing Floor Pian
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 WINDdW.
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
�
1:'►.
•
�[Ilb�
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 UNT[L PROCESSED
I hereby apply for a buitding 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 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 ork hich re u'res review and approvai of plan /
SIGNATUREOFAPPLICANT PRINTNAME �SCCC .� /�?,�ct...��-/�DATE � Z 3 ' �,'O %f
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