P - 35408Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � / '� /
S1TE ADDRESS �
THIS APPLICANT [S:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MA1L ADDRESS �
� P�� �' �� �
❑ OWNER �CONTRACTOR
PROPERTY OWNER/ � NAME:�
TENANT qpDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LtCENSE
AND CERTIFICATE OF
INSURANCE
0
Permit No.: �''�'���- �'� �
r:
Received By: � �
Date Rec'd: �7,.� � �
STATE�IP,
NAME: ✓� � 1 � 5, i
STATE LICENSE/ #�j'' LEAD CERT NUMBER !/v,� T�r! � S�
ADDRESS: (9 Y�I �,�{��—�i�r N CITY �►j(Ai�� G�Jb�STAT��NZIP.
PHONE �%6 3" � Z 7- �� a b FAX
PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRL3CTlON S1zE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
❑ BASEMENT FINISH
❑ D�CK
❑ NEW HOME CONSTRUCTION
� MAINTENANCE/REPAIR
-. •s�e.r � .� ✓ �1J
ROOFING n �
NUMBER OF SQUARES Ci
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
O Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENR�fG CHANGBS &
TYPE OF WINDOW TO BE INSTALLED
❑ GARAGElSHED ❑ WiNDOWs
� ROOF O DRARJ TILE
❑ SIDTNG ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
� HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER
FT
BASEMENT REMODELING SUBMIT�
I . Existing Floor Ptan
2. Proposed floor plan
3. List of strucWral members to be used
FOR NEW CONSTRUCTION MCLUDTNG DECKS,
A17DIT10NS. & PORCHES SUBMIT:
l. Sitc Plan/Survey showing the existing sVuctures
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:
(U5ING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ �� OCCUPANCY TYPE
Pertnit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
5AC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
�
��/
a�
�
� 1/l��-'f'�
See Back Page for Pee Schedule
65% of.Building Permit Fee
.001 times the total }ob 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 pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a pe it and rk is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all rk whic re i s review approval of plan�s.� � � � �J �%2& /l �
StGNATURE OF APPLICANT PRINT NAME ��� (l�0� DATE � �
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