P - 48265Building
Inspections
763-5�z-�4
763-502-4977 FAX
DATE � �,' � �9- ( 4"� � �
SITE ADDRESS �Q � � Q tJ
THIS APPLICANT IS: �
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
iNSURANCE
TY TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT►VE 1-1-2011
YOUR E-MAIL ADDRESS
�(, ��- L_P) l A i""r'
OWNER OCONTRACTOR
nDDttESS:�,p ��, � � 9� � u�, t n�.
PHONE: � �T��2. — �J �o U —y �"� %�
e
Permit No.: ��b1�rU �
Received By:,�
Date Rec'd: _
A
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: CITY STATE ZIP
PHONE FAX
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
� TWO FAMILYMEW CONSTRiIt'TrnN---� STORIES
PERMIT TYPE � �DITIOtv � ❑ Ga,R,aG
❑ BASEMENT�FINISH ❑ ROOF
❑ DECK ❑ SIDING
__ _
TYPE OF WORK:
, DESCRIBE WORK
' SIZE OF [MPROVt
ROOFING �
, NUMBER OF SQUARES _
; GARAGES
i PROPOSED SIZE:
' PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ N E CONSTRUCTfON ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
.�:
, . �. _ -� :: ` LENGTH ° T WiD
❑ HOUSE & GARAGE
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
u
wtt�DOws
�tbSIN TILE
N�ul �L.�
HEIGHT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Caiculations
FOR WINDOWS – PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $� j r� �US a�G THE 1997 U.B.0 FEE SCHEOCCU ANCY TYPE
Permit Fee $ o � 5 See Back Page for Fee Schedule
Plan Review $ �, 65% of Building Permit Fee
Fire Surcharge $ 45b .001 times the total job valuation
Surcharge $ �'� 5 .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge �$ Agreement necessary () Non Necessary ()
Total Due $ . .y� Make checks payable to: City of Fridley Attach St�
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 f th ty of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit nd w k is not to start without a permit on site; that the work will be in accardance with the
approved plan in the case of II w rk which re ir review and approval of p�! sj`
SIGNATURE OF APPLICANT �¢..►� PRINT NAME E.L(,T'M�,Ie't Y� ��ll� DATE I I��%��0' I�
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