P - 35845Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTI�L APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:
Received B :
Date ���
DATE J' d— — l` YOUR E-MA[L ADDRESS ��N 0����"1 � V�it�'j I�� d V"�
SITE ADDRESS S S�. S L' �3.�JC� �f"'� c9-�/1 �cx5 �
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ I N,a�tE:�
TENANT e,DDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
NAME:�
STATE LICENSE #
PHONE (o �- d 3�� G Si� a--
❑ SINGLE FAMILY/NEW CONSTRUCTION
'� TWO FAMILY/NEW CONSTRUCTION'7;
PERMIT TYPE � �DITION
❑ BASEMENT F[IYISH
❑ DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
1S DING
❑ Vinyl
❑ Aluminum
❑ Other
CITY�,G,�L► Q,_ STATE�ZIP.
LEAD CERT NUMBER
CITY — 1 �'�� STATE�ZIP 55y 3 a=
FAX '�'
SIZE � 00
.9�SQ, STORIES �
❑ ROOF
❑ SIDING
O SWIMMING POOL
❑ ADDITION
'R�] REMODELING
O HOUSE ONLY
❑ HOUSE 8c GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GAItAGE
OSoffit
0 Trim
❑ Fascia
WINDOWS
IN EXISTMG OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF \
❑ DRAIN TILE
�OTHER
����
HEIGHT
FT
BASEMENT REMODELING SUBMIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION [NCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT
l. Site Pian/Survey showing the existing structures
and proposed project.
2. Two sets of conswction 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:
COTAL JOB VALUATION $�N��;IE(�7 U.B.0 FEE SCHO CUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ vv
�b
$ �d
$
$
$
$
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$24=$
$450 Conservation Plan Review ;�
Fee Determined by Engineering �
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridle_y Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appIy 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 o ity of Fridl and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a pe it and wor is not start without a permit on site; that the work will be in accordance with the
approved plan in the case of al k w' q es re 'ew nd a rov l of t
AP RO AL�INSPECTOR GNAT / / pp�`�Ep �� � ��� DATE � � ^ � �