P - 35966Building
Inspections
763-572-3604
763-502-4977 F
DATE
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/
TEI�TANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
Permit No.:
Received By:
Date Rec'd:
YOUR E-MAIL ADDItESS 1�� C� ��� `'n V T� h(j V.x�4J �01'
`
ADDRESS: S� �U l�� S�'N� CITY 'r� � I STA� �ZIP
PHONE: `Z4' � ta-v�6� °" UZ-o,�
NAME: `^ V� � � 1
STATE LICENSE # O� Z LEAD CERT NUMBER
ADDRESS: I � I I e L`. N CITY Cl � 4�S,TATE�IP�
PHONE __ /__l_� Z .- � '1 � " Z� � V FAX 7 In � " '% �f �O " �� � I
� SINGLE FAMILY/NE'W CONSTRUCTII
❑ TWO FAMILY/I�[EW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SF
❑ BASEMENT FINiSH �OOF
❑ DECK SIDING
❑ SWIMMING
STORIES
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDiTION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: q �C � v0
S1ZE OF IMPROVEMEI�iT LEA3GTH WI TH
ROOFING E� ❑ HOUSE ONLY
NUMBER OF SQUARES � �HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
❑ DRAIN TILE
� OTHER
HEIGHT
FT
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,
i❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim l. Site PtanlSurvey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFAC?URE 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:
(USI�iG THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �% O 0t� • D� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$ �j �! , aCS
$
$ ` —
$ 1,�
$ � � t�
����jr
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= 8x$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridlev 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 application for a perm' and is t start without a permit on site; that the work will be in accordance with the
approved plan in the case of all ork wh' h e re n approval of plans.
SIGNATURE OF APPLICANT PRINT N�'1 E DATE
APPROVAL INSPECTOR SIGNAT E /.IJ U
2�.�Z �