P - 40016Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_�i
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
�( OWNER
ADDRESS:
PHONE:
NAME:
STATE LICENSE #
ADDRESS:
PHONE
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:
Received B�
Dat��' d:
E-MA1L ADDFZESS �G��! ) , �.VG �Y�C� � CC�f�1
' o .
❑CONTRACTOR
1"7�f `i'1' G(�1V S'� � CITY �� � STAT� � ZIP���yj5��
- 7l 7.�-.—
LEAD CERT NLIMBER
FAX
[�y'1
�kSINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
Q! MAINTENANCE/REPAIR ❑ REMODELING
DESCRiBE WORK BEING DONE:
SIZE OF IMPROVEMENT
LENGTH — WIDTH HEIGHT
STATE Z[P
FT
! ROOFING � ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
I NUMBER OF SQUARES � ❑ HOUSE & GARAGE
i 1. Existing Floor Plan
i GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
�, PROPOSED HEIGHT: C�, �,�N N E
SIDING FOR NEW CONSTRUCT[ON MCLUDING DECKS,
❑ V i n y i ❑ S o ff i t V ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim L Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF W[NDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR 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 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �� .001 times the total job valuation
$ o ��Q_ .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 ( )
$ �.(11.1 Make checks payable to: City of Fridley 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 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 all/� Qrk w ich re res re e nd approval of plan ` ' /
SIGNATURE OF APPLICANT 1 A�� YU.�PRINT NAME��1�C1^� i rG�RI�--� DATE e� I�� I I
APPROVAL INSPECTOR SIGNATLJ�1� ° , T�
�
!
BUILDING PERMIT APPLICANT: PROPERTY OWNER
,
I, ����t J , understand that the State of Minnesota requires
that all residen�ia building con ctors, remodelers and roofers obtain a state license
unless they qu ' for a specific exemption from the licensing requirements. This license
requirement applies to owners of residential real estate who build or improve such
property for purposes of speculation or resale.
By signing this document, I attest to the fact that I arn improving this house for my own
use and am not building or improving this house for the purpose of reselling it. I hereby
claim to be exempt from the state licensing requirements because I am not in the business
of building or remodeling on speculation or for res and that the house or whic I
applying for this permit, located at _��j''o2$� �1( � 1� S��- �' ��
is the only residential structure I have built or improved in the past 24 months. I also
acknowledge that because I do not have a state license, I forfeit any mechanic's lien
rights to which I may otherwise have been entitled under Minn. Stat. §514.01.
Furthermore, I acknowledge that I may be hiring independent contractors to perform
certain aspects of the construction or improvement of this house and I understand that
some of these contractors may be required to be licensed by the State of Minnesota. I
understand that unlicensed residential contracting, remodeling, and/or roofing activity is a
misdemeanor under Minn. Stat. §326B.082, subd. 16 and can also result in a fine of up to
$10,000. I further state that I understand that the filing of a false statement with
The Citv of Fridlev may also result in criminal prosecution and/or civil penalties
to applicable city ordinances and/or state statutes.
I have also been informed and acknowledge that by listing myself as the contractor for
this project, I alone will be responsible to The Citv of Fridlev for compliance will
all applicable building codes and city ordinances with the work being preformed on this
property. `�/
ig t r of P perty w er
' Date
For questions or information on contractor licensing, or to check the licensing status and enforcement
history of a particular contractor, call the Minnesota Department of Labor and Industry, Construction
Codes and Licensing Division, at (651) 284-5069. The web site is: htt�://www.dli.mn.�ov/Ccld.asa