P - 35230Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
DATE_�� . f � ( f -
SITE ADDRESS ' � �� (�
THIS APPLiCANT IS: ❑ OW1�iER
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
E-MAIL. ADDRESS
_ , --
PROP TR N A OT NER/ NAME:_�(,T�"-r �y�� /e�
ADDRESS:
PHONE:
CITY
Permit No.:��' ( I �' �-✓ ��
Received By: � � r '
��x���: � � 2011
STATE Z1P
CONTRACTOR -��J ' `
NAME: � f%'� / � +� � � ii -n 7 �--� ( � ~l� '�
SUBMIT A COPY OF /
YOUR STATE LICENSE STATE LICENSEt# zU�p �j�;� I l� A LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: ��{ ,S `�i � i'� ^ f ,� i �� CITY /�_„� STATE.�n.�ZIP
INSURANCE PHONE %C � ' i i S _ ��� ` i _ F,q}{ .>• ��.•
PROPERTY TYPE ;,�SINGLE FAMILY/NEW CONSTRUCTION
O TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK:
❑ SIDING
❑ SW'IMMING POOL
SIZE
STORIES
❑ WINDOWS
❑ DRAIN T1LE
❑ OTHER
O NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR : . ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
F200FING l
NUMBER OP SQUARGS �?`'.�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
«'INDOWS
IT! EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WiNDOW TO BE INSTALLED
�.:=
❑ HOUSr ONLl'
❑ HOUSG & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF V✓INDOWS
NUMBER OF WINDOWS
WIDTH HEIGHT
FT
BASGMENT REMODI�LING SUI3MIT:
L Existing Floor Plan
2, Proposed floor plan
3 List of structural members [o be used
FOR NEW CONSTRUCTION fNCLUDTNG nECKS,
ADD1TlONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing strucmres
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)
['OTAL JOB VALUATION � OCCUPANCY TYPE
Permit Fee
P►an Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �jrj.L�e�
$
$
$ �� �
$ .i�°�.�
$
$
$
$
$
$ I ( ,'�� �'_
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
0005 x Permit Valuation Minim�m $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 �avable to: Citv of Fridlev
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMfT-NOT VAL1D UNTIL PROCESSED
I hereby apply for a building permit and T 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 fo rm' 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 or re �res review and approval of plans �
( /{ � ~-7 "�
S1GT�'ATURE OF APPLICANT %�=' t` ' PRINT NAME_�����1 �.�� '2-� DATE / �7C �" ��
AP°ROVAL INSPECTOR SIGNATJ�`R� � ' '—�
PLEASE