P - 35960Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ^ � � ` i
SITE ADDRESS `"�%/,% �i
—T°�—
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
� INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE i-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
NAME: �..t�t. '�'�-�« d���hR�i!'!�n'+.s-G
ADDRESS: CITY
NAME: ���"v�,,'""
STATELICENSE# 6��
ADDRESS:
PHONE ! (�] � " ! ,�'� "/ "
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH �bOF
❑ DECK � SIDING
❑ SWIMMING POOL
Permit No.:
Received By:
�
`#- ,1 � -i
ATE ZIP
CERT NUMBER
CiTY STATE ZIP
FAX
SIZE
STORIES
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR O REMODELMG
DESCRiBE WORK BEING DONE: "'O � � l�� 1
SIZE OF IMPROVEMENT p�-� LENGTH WIDTH
R FING ❑ HOUSE ONLY
NUMBER OF SQUARES i�� ❑ HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
❑ DRAIN TfLE
❑ OTHER
� /N� /
HETGHT � SO FT
BASEMENT REMODELINC SuBMIT:
1. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
': SIDING FOR NEW CONSTRUCTION TNCLUD[NG DECKS,
; ❑ V+nyl ❑Soffit ADD(TIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim l• Site Pian/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 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.
OPENMG CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, IIVCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�%�. C�� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �" I• d J 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 navabte 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 d codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application a permit 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 al ' requires review and approval of plans. ����,/ r
SIGNATURE OF APPLICANT PRiNT NAME DATE /
APPROVAL INSPECTOR SIGNAT RE