P - 42130Building
Inspections
763-572-3604
763-502-4977 FAX
DATE , ' �=
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
I AND CERTIFICATE OF
' INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SiZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
O Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2011
R E-MAIL ADDFtESS
❑ OWNER
NAME: , %�i�e �
ADDRESS: Co `J�,�(.� .y�,/c: c� 7— //
PHONE:� �j ` 7 �� — �,�
STATE LICENSE #
PHONE ' % � !`' 1i' `7"'/ — c�Ca(�CJ
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
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
OF WINDOWS
CITY
Permit No.:��% � � �
Received By:
Date Rec'd:
TAT�i,�ZIP S�°I3�
,D CERT NUMBER ' � � � �
CITY STATE��Cd/GIP
FAX
❑ DRAIN TILE
❑ OTHER
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING 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
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTALJOB VALUATION $ 2�3� OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$
$
$
$ ..
TERIALS:
TYPE
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 Pian Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: C�ty of Fridlev Attach
lations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a building permit and I acknahd edge at the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the Ci ridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and wor ' ot to start without a permit on site; that the work will be in accordance with the
approved plan in the case of Y wor c re ' s r ' w and approval of plans.
SIGNATURE OF APPLICANT RINT NAME DATE
APPROVAL INSPECTOR SIGNATURE .�