P - 35490Building BUILDING
In 1 ettions RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE `��� � r j�_ S� YOUR E-MAIL ADDRESS
S[TE ADDRESS
THIS APPLICANT IS
� PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
,�WNER
ADDRESS
PHONE:
❑CONTRACTOR
+ r1�
Permit No.: L�{ f �
Received By: �
Date Rec'd: �lo��
CITY�(� c�Sr� Jtl\� j� pr�l� STATE�ZIP
NAME: �r�.4��i� �l���t � ('a (� C� �cze ��. �
STATE LICENSE # �_ �
PHONE ' /(0��"Q'� { � U CG
[7 SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE � �DITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMING AO(
FAX
S[ZE
STORIES
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
0 MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES ,�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SLDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
CITY STATE Z[P,
❑ DRAIN TILE
❑ OTHER
HEIGHT
�
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor pian
3. List of structural membcrs to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
�Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project. .
2. Two sets of construction plans
WINDOWS� 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR W(NDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WiNDOW.
OPENWG CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
USING��IE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $`� �� d• OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota1 Due
�3.SV
$
$
s
$ J
$ S�
$
$
$
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 (
Make checks aavabie to: Citv of Fridlev
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby appty for a building permit and 1 acknowledge that the information above is complete and accurate; that the work will 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 rmit d work is not to start without a �ermit on site; that the work will be in accordance with the
approved plan in the case of ot wh' yuiresreview and approval of pt�,n�.
SIGNATURE OF APPLICANT PRINT NAME v � l _T DATE �, �� 7� %�
APPROVAL INSPECTOR SIGNATURE
. �
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