P - 45136Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � � � � I
SITE ADDRESS �SCZ�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-I-2011
YOUR E-MAIL ADDRESS
❑ OWNER
u�
ADDRESS:
PHONE:
; �,,� LLC
Permit N
Received By: 'm��
Datc ��t1:Q � � � �. 2 � �'�
ATE ZIP
STATE LICENSE # ZO (o `3-2 S l(o LEAD CERT NUMBER
ADDRESS:_ (�{ 5 K� 1�.�.�a' S�. %Ul� CITY H'�'►�+�• L�- � STATE 1�"nJ ZIP
PHONE �(oS- YKS- /(o`�y
�SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
GARAGE/SHED
❑ SIDING
❑ SWIMMING POOI,
FAX
SIZE
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �
SIZE OF [MPROVEMENT L.ENGTH WIDTH
ROOFING 2 � HOUSE ONLY
NUMBER OF SQUARES J3 ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
� WINDOWS
� IN EXISTING OPENINGS ❑Yes ❑No
j OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Pian
2. Proposed floor plan
3. List of structurai 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 WMDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
! TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totat Due
� ���•S►
+ ,..,r
'�iti
E!i�i3IR
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)
f}+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPL[CATION FOR A PERMIT-NOT VALfD 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 Frid]ey and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application • 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 quir eview and approval of pla ,, O
SfGNATUREOFAPPLICANT PRINTNAME ��� �-tJ� DATE le "�/' �I
APPROVAL INSPECTOR SI ATURE