P - 37488Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS _
THIS APPLICANT IS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRI�LEY
EFFECTIVE 1-1-2011
YOUR E-MAlL ADDRESS
❑ OWNER ❑CONTRACTOR
PROPERTY OWNER/ N�vtE: �('
TENANT pDDRESS: � � GO 7 --�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PHONE: E!/aZ-.S 95-- a a 3 g
CITY
Permit No.:�( -�;� � ����
P
Received By: /��
Date �1.��-�„ ` _ '�
�,., ,.
TATE� /� ZIP , S�
rratvtE: � � ,�� /� v � ; d ,�a�.A� -� � n
STATE LICENSE # �� � �� �I � � LEAD CERT NLIMBER
ADDRESS:_� �O �'7 /�Q..,/'�,� S�j CITY ��• �,�nl ��_STATE�ZIP S f U ��
PHONE 7� S—a 3�'C-, 07� FAX
�f SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE � �DITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
❑ GARAGE/SHED
� ROOF
❑ SIDING
❑ SWIMMING POOL
S[ZE
STORiES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCE/REPAIR ❑ REMODEL[NG
ROOFING � 6 S �
NUMBER OF SQUARES _�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINC:S ❑Yes OI�lo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
� HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
�Wl��� ` �1[sl;T1�1
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION �NCLUDING 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 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
I Park Fee
� Sewer Main Charge
! Total Due
$ �I��,�.5
$
$ z (n f
$ �
$
$
$
$
$
$
$ '1.In�I
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 aavable to: Citv 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 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 c-vahich requires review and approval of p�jax�s. G `
SIGNATURE OF APPLICANT `��---�" PRINT NAME / rea� ����'•' �� -j DATE O'�3 �/
APPROVAL INSPECTOR SIG E