P - 45308Building
Inspections
763-572-3604
763-502-4977 FAX
UILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:
Received By:
Date Rec'd:
DATE ��5���� YOUR E-MAIL ADDF2ESS �%/��'Z �S`�� /Gf"� C�(;X�c1 J�o �Q
S[TE ADDRESS _ �!�D �3��i�.rn�v� S-f N2
THIS APPLICANT IS: I�OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME:�
TENANT ppDRESS:
PHONE: '
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
1NSURA.NCE
PROPERTY TYPE
NAME:��
STATE LICENSE #
ADDRESS: S��i
z
rnvivr. (/J /`'"' C�a.� /""- Z b evG
6�'SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ �DITION
❑ BASEMENT FINISH
❑ DECK
TY.PE OF WORK: ❑ NEW HOME CONSTRUCT]ON
[�.MAINTEN ANCE/REPAIR
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyi
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS es ❑No
OR FOR NEW OPENINGS- ESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
_CTTY �i'�/'c.1 /c.° STATE�ZIP�>S�
�r2-3�s�s �3� �
LEAD CERT NLJMBER
CITY STATF/�/I/LIP—"-�—F�
FAX
SIZE
STORIES
❑ ROOF ❑ DRA]N TILE
f] SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
0 Fascia
LOCATION OF WINDOWS
NUMBER OF
WTDTH
HEIGHT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. 5ite Plan/Survey showing the existing structures
and proposed project.
2. 'Cwo 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 $� p , t� 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
$ "' c�-�
$
$ ��
$
$ ��'. J
$
$
$
$
$
$ � , r'�.�
See $ack 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 (
Make checks payabie 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 tl�e 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 al or which uires review and approval of pla p
SIGNATURE OF APPLICANT ���� Q. � PRINT NAME ���t �N ��i'rtZ DATE 7 Q"I�
APPROVAL INSPECTOR SIGNA E �