P - 35116Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ���I�/lf
SITE ADDRESS �
TH[S APPLICANT IS
PROPERTY OWIVERI
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSUR.ANCE
BUILDING
RESIDENTIAL APPLICATION
CIT�' OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.: ��
Received By: ` `
Date Rec'd: � i
YOUR E-MAIL ADDFtESS �. Z.�L, �c�f. S4� ��. G,� � p/'1 �c:� �/c+�c G'K7 GL7 /vt
7����` S�
�WNER ON O �
NAME: l.'l � a yh
ADDRESS:_ b�L/(� �`� �` S� �V � CITY f i��t �� STATE J'k4% ZTP SS� 3 Z
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STATE LICENSE #�a 6� �( �/� O LEAD CERT NL)MBER
ADDRESS:_ � S�DO 7'n ;,,Q �r ,u �,, CITY IZ� STATE 1'�iWZIP SS3� 3
PHONE �w I Z� C� G� I Z�( G FA X
PROPERTY TYPE �C�S.lNGLE FAMILY/NEW CONSTRUCTION
O TWO FAMILYMEW CONSTRUCTION
PERMIT TYPE � �DITION .
❑ BASEMENT FINISH
❑ DECK
TY.PE OF WORK: ❑ NEW HOME CONSTRUCTION
❑ MAITITENANCE/REPAIR
DESCRIBE WORK BEING DONE: UL c— K W
ROOFING
NUMBER OF SQUARES `Z-Z-
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS OYes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE tNSTALLED
„f�ROOF
❑ SIDRJG
❑ SWIMMING POOL
� ADDITION
�REMODELING
❑ HOUSE ONLY
�iOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBBR OF
❑ DRAIN TILE
D OTHER
BASEMENT REMODELING SUBMIT:
t. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTiON fNCLUDiNG 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 WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING� E 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ �(`� —��, -`' OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Contro]
Park Fee
Sewer Main Charge
Total Due
$ J
$ r�i
$ � ��
$ J`—, c�
$
$
$
$
$
$ n.
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 F'ridley
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 ordinan es 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 e't and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the cas o 11 � requires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME DATE