P - 35406Building
Inspections
763-572-3604
763-502-4977 FAX
DATE L—�
SITE ADDRESS
THIS APPLICANT IS:
— l
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
PROPERTY OWNER/ I NAME:_
TENANT
ADDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
OF
YOUR E-MAIL ADDRESS
NAME: T �J v
STATE LICENSE #�
ADDRESS: 2 �O Z1
r�
�9
PH C.Qt� S� I.�� Z�
SINGLE FAMILY/NEW CONSTRUCT]ON
WO FAMILY/NEW CONSTRUCTION
❑ ADDITION ,❑�_ �G $AGE/SHED
❑ BASEMENT FINiSH iBOOF
❑ DECK ❑ SIDING
❑ SWIMMING POI
❑ NEW HOME CONSTRUCTION �❑���
❑ MAINTENANCE/REPAIR _ �REM
ROOFING %��
NUMBER OF SQUARES E�"�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
� Vinyl
O Aluminum
O Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WTNDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
O Fascia
LOCATION OF WINDOWS
t�IUMBEROF WINDOWS
Permit No.:
Received By: �
�;CC: u'e� � • �
STATE�IP
CERT NUMBER
CITY �t�°C._ STATF,�ZIP�37d
FAX
SIZE _^^
Q WINDOWS
❑ DRARJ TILE
❑ OTHER
FT
BASEMENT REMODELING SUBMlT:
!. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDIIJG 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:
� (�I�HE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ �l 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
$ � ��� �� 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 ( )
$ 4Q;� l.� � Make checks pa_yable to: City of Fridle_y 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 w k is ot t start without a ermit on site; that the work will be in accordance with the
approved plan in the case of a� e � approval la s. �/,�/�� >/�
SIGNATURE OF APPLICANT AME ��' l Wl/ ATE �^�� <�
APPROVAL [NSPECTOR SIGNATU