P - 35496Building
Inspections
763-572-3604
763-502-4977 FAX
DATE `I C.�d ���
S[TE ADDRESS `1�
THIS APPLICANT [S:
PROPERTY OWNER/
TEI�TANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE .
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING DO
SIZE OF tMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
BUILDING
Permit No.: ����ad
RESIDENTIAL APPLICATION Received By: IV Y'`
CITY OF FRIDLEY Da1��°d�AY � 2 2 1
EFFECTIVE 1-t-2011
YOUR E-MAIL ADDFtESS � � C7 Sii� L�'I^ ��%Ci�I��y(;� ,�,�
� 1�i,�ec�S � . �ic�' Rr. �1.•.�
�OWNER ❑CONTRACTOR
NAME: �
ADDRESS:
.,,.�,.r,-. ,
iu
CITY Fr��kl/ STATE�N ZIP.
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: CITY STATE ZIP
PHONE
LE FAMILY/NEW CONSTRUCTION
FAMILYMEW CONSTRUCTION
❑ ADDITION ❑ GARAG
O BASEMENT FINISH ❑ ROOF
� DECK ❑ SIDING
❑ SWIMM
O NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
SIDING �
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �IVo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
ALL FEES ARE BASED
TOTAL JOB VALUATION $ '
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge -
SAC C�arge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota! Due
FAX
SIZE
STORIES
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
O HOUSE & GARAGE
O ATTACHED GARAGE
O DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOC��AbT]X Q�WINDOWS
�{
NUMBER OF
� DRAIN TILE
❑ OTHER
HE[GHT
FT
BASEMENT REMODELING SUBMIT:
l. 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 Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW. �
VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 199'7 U.B.0 FEE SCHEDULE)
°" OCCUPANCY TYPE
$ a$.Z(� 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 payable to: City of Fridley Attach
lations
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 c s of the C' of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permi nd w 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 which r uir review and approval of pla �^
SIGNATURE OF APPLICANT RMT NAME �Ino��C. l�t.S DATE ci' Z" II
APPROVAL INSPECTOR SIGNAT RE . '
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