P - 35326Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �
SITE ADD ESS _
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL
❑ OWNER
PROPERTY OWNER/ NAME: /
TENANT
ADDRESS:
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
STATE LICENSE # Z
ADDRESS: I ZD i S
��:�� �
❑ SINGLE FAMILY/NEW CONSTRUCTION
�i "i'WO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
0 BASEMENT FINISH ❑ ROOF
� DECK ❑ SIDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEiNG
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
0 Vinyl
0 Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes QNo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED ir� i.
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
CITY '
7 l �
LEAD CERT NUMBER
� CITY��
� F,ax FSL ��'Fr
�
S[ZE
STORIES
�WINDOWS
❑ DRAIN TILE
❑ OTHER
NG
�� .,✓G
�
)TH HEIGHT
(1 K-C/' NUMBER OF WINDOWS /
Permit No.:� � 5��
Received By•
D��°�:pR 2 6 2011
/ '� C�,a..�SdS'�ii'l6�
�
STATE ZIP_
�-�STATE/�'1�IP,
_/_�Qr
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of suuctural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. $ite Pian/Survey showing the existing sWctures
and proposed project.
2. Two seks of construction plans
3. Energy Calculations
FOR W(NDOWS — 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)
TOTAL JOB VALUATION $^%00 � OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrvw
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ L�1. (,�ii See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ _`'�Q .001 times the total job valuation
$ 3`(� .0005 x Permit Valuation Minimum $5.00
$ 'r'j_ $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 �avable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building ermit and 1 acknowledge that the information above is compiete and accurate; that the work will be in
conformance with the ordinan s and codes the ity of ridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicati for a pe t an ork is to start without a permit on site• that the wo k will be in accordance with the
approved plan in the case o ork r res re ' and approval of pl s✓. C
S[GNATURE OF APPLICANT INT NAME 1 r46( 5{,rWL DATE �