P - 35232Building
Inspections
763-572-3604
763-502-4977 FAX
DATE���� �(
SITE ADDRESS �-�G%.� `
TH[S APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2011
YOUR E-MAII, ADDRESS
�$WNER ❑CONTRACTOR
PROPERTY OWNER/ Nq�E ���� r�/� �� f�;�f-
TENANT pDpRESS:�,_�%� �jj//�i2 �:,j;_..�c.- C1Tv
PHONE: .7�5� —�f� ��._��%
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE �
AND CERTIFICATE OF ADDRESS:
INSURANCE PHONE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK
Permit No.: �+ �
Received By: ,��,� —
Date R��� ' J U� �.. F� �
�� STA
LEAD CERT NUMSER
CITY
FAX
�INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WiNDOWS
❑ BASEMENT FINISH 1��i00F ❑ DRAIN T1LE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADD1TlON
��IAINTENANCE/REPAIR ❑ REMODELING
D6SCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT �
ROOFING
NUMBER OF SQUARES "�� `
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENRJG CHANGES &
TYPE OF WINDOW TO BE INSTALLED
O HOUS6 ONI.Y
�-HOUSE & GAftAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
WiDTH � �� NEIGHT
Z�p '-� ��-� �.
STATE ZfP
FT
BASGMENT REMODELING SU13M1T:
I . Existing Floor Plan
2. Proposed floor plan
3 List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDTNG D6CKS,
ADDI7'IONS. & PORCHES SUBMIT:
I. Site Plan/Survey showin� 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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION � 1 i%%� � 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
$ ` tj 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 ( )
$ I(, ��_ `a Make checks payable to: City of Fridley Attach Stipulations
THtS 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 wil] 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 a1> 1 wor wh��h requ' e yeview and approval of pl s l f
SIGNATURE OF APPLICANT %"; ` � �" � � �r �� PRINT NAME ; '� �_�e' ,✓ . ��c �✓� DATE �?`=?;�i/
APPROVAL INSPECTOR SIGNATURE , a ` �
PLEASE NOTE: SEPARATE PERMTTS ARE It�QUIRED FOR PLLJMBING, ELECTRICAI, AND MECHANICAL W�RK
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