P - 48088Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER OCONTRACTOR
NAME:
ADDRESS: � 7 G� 7{� c5 �'iV _ CITY
PHONE:_ 7�� ` S 7 y- q y o�
Permit No.: '-�� � �`� �+��11
Received By.
D���'� ` '��%_.� ����
'ATE mA, ZIP S�
CONTRACTOR NpME: �` `,r(�O� �„`S�.rvC�lp,� � �
SUBMIT A COPY OF STATE LICENSE # �, O 6��J G I I LEAD CERT NUMB�ER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: 3%S% I/�l ��' L,� ]�(,� CITY (`ppv` c�(�?� STATE �A1ZIP S_�,�
INSURANCE pHONE �% - S I —�'I % S FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF [MPROVEMENT
❑ BASEMENT FINISH Q'ROOF
❑ DECK ❑ SIDING
❑ SWIMM
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
ROOFING
; NUMBER OF SQUARES � �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl psa�� ADDITIONS. & PORCHES SUBMIT•
❑ Aluminum ❑ Trim I. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WTNDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
T'OTAL JOB VALUATION $ OCCUPANCY TYPF.
I Permit Fee
� Plan Review
� Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due _
$ �'], %�
$
$
$
$
$
$
$
$
Q
$
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 Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 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 work w�} ch r qui • 3� review and approval of plans. O
SIGNATURE OF APPLICANT �/'/� PRINT NAME �, � �..{�p xa��p, DATE � V� �� I�
APPROVAL INSPECTOR SIGNATU��p° �