B - 41737Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ����'� � �
SITE ADDRESS '
THIS APPLICANT IS:
\�
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
Permit No.: ��'l� ��f✓,�
Received By: .J��'� 1� +� � "�
Dat����d��� d � ����
PROPERTY OWNER/ NAME: G A� �. �, y4�' a
TENANT pDDRESS: "1 5(� �) S��`ict �a ••,i Q�p,t E CITY 'Fr: ��ti STATE�ZtP
PHONE: i b"3 ' � ri'�( ^`i ��o�
CONTRACTOR
SUBMIT A COPY OF
YOUR STAT� LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
NAME: � �£...�.'� s� c� i o v s
STATE LICENSE # a � (v 3
ADDRESS: �� � i
PHONE ��% I � � � ��
L9rSINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: � � NEW HOME CONSTRUCTION
$1 MAINTENANCE/REPAIR
DESCRI$E WORK BEING DONE: EZ ��` c�� �-
SIZE OF IMPROVEMENT
ROOFING /� a�
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
M EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING Ci-IANGES &
TYPE OF WINDOW TO BE MSTALLED
Q GARAGE/SHED
I�ROOF
❑ SIDING
Q SWIMMING POOL
.D CERT NUMBER
1'%1CITY � �' �.(/l. STATE�ZIP'
FAX
SIZE
STORIES ,�
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
❑ DRAIN TILE
❑ OTHER
HEIGHT
fiT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION (NCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing 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)
TOTAL JOB VALUATIUN $ 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
$
$
$ �,
$ v�
$
$
$
$
$
$ %�'
See Back Page for Fee Schedule
65% of Building Permit Fee
.00 t 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 payable to: City of Fridlev
Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit d I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and od s 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 e it 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 a re uires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME M• O�:vf [�,b,j S DATE �O - 3'\�