P - 35810Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ` � U '
SITE ADDRESS
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
OWNER
PROPERTY OWNER/ I NAME: ,
TENANT qDDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMTT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
YOUR E-MAIL ADDRESS
C • �,�, _ ,� �..�
0
CITY
Permit No.:
Received By: �
D��c�:
a�,�+� ztP 55H3�
..�v.. • �ww�--as- �"��� � � 1'J/iv (7
STATE LICENSE # �Ojo 3vyy �v LEAD CERT NUMBER
ADDRESS: 3�i J �I 'dn' � CITY� �,n � STAT6 '�'�ZIP 55303
PHONE 7G �• o��P "S°l� 6
'�CSINGLE FAMILYMEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �'j200F
❑ DECK ❑ SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION'
❑ MAINTENANCE/REPAIR � REMODELI
ROOFING
NUMBER OF SQUARES vZ- ��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
� HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
FAX
SIZE
STORIES
WtDTH
❑ DRAIN T1LE
❑ OTHER
SQ FT
BASEMENT REMODELING SUBMIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
SIDING FOR NEW CONSTRUCTION RVCLUDING DECKS,
❑ Vin I ADDITIONS. & PORCHES SUBMTT•
Y ❑Soffit
O Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ '%. Z. See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ Q .001 times the total job valuation
Surcharge $ l a .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
, Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Tota1 Due $ �� ��— Make checks pavsble to: Citv of Fridiev - Attach Stinutatinnc
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESS$D
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 cod i the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f pe nd work is not to start without a rmit on site; hat the work will be in accordance with the
approved plan in the case of all k equires review and approval of pl
SIGNATURE OF APPLICANT PRINT NAME /V � DATE �' I� ` I�
APPROVAL INSPECTOR SIGNA U E