P - 39626Building
Inspections
763-572-3604
763-502-4977
DATE a��l/
SITE ADDRESS _
THIS APPLICANT IS:
AX
d
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
' _YOUR E-MAIL ADDRESS
�
❑ OWNER �6NTRACTOR
PROPERTY OWNER/ NqME:
TENANT
ADDRESS:
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME: (i�/S'7L v�' ��6,Tt U"�S
STATE C,ICENSE # D ,3 �p 6 .S—
twQxESS: Zu l 7 ��c w�e
PHONE �/ � '" %U �u ' !(QO/ S FAX (p/ � ,
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION Q GARAGE/SHED � WINDOWS
� BASEMENT FINISH .�OOF ❑ DRAIN TILE
❑ DECK ❑ SIDiNG ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: 1` �� ^'
SIZE OF IMPROVEMENT LF.N('�TH
CERT
CITY
ROOFING
NUMBER OF SQUARES __�_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENR�IG CHANGES &
TYPE OF WINDOW TO BB INSTALLED _
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF WMDOWS
WIDTH
Permit No� � � —C� ��
Received By: �
Date Rec'd: � �
STATE ZIP
�STATE�(l�IP lf,%
-- 963 d
FT
BASEMENT REMODELING SUBMIT:
i . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION 1NCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction ptans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WiNDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LASOR 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
$ �5. 2'j See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ � 2 .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 pavable to: Citv of Fridlev Attach
ulations
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 code f Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application far a � nd c� o start without a per it on site• that the work will be in accordance with the
approved plan in the case of all �ch �r d approval of plan . •
SIGNATURE OF APPLICANT , i�`�T �ME � �li�. DATE � �/
APPROVAL INSPECTOR SIGNATURE / �(/� /J�,(� �t