P - 46505Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ����/C3i
SITE ADDRESS ((�(G
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:
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YOUR E-MAIL ADDRESS %?U�'�'+� � C ����/� �a�
S7 � `�CaAC�i /n�° SCy.72
❑ OWNER
PROPERTY OWNER/ NAME:
TENANT ADDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
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STATE LICENSE #
ADDRESS:�
PHONE 1S-Z
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'SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
CITY ���� �% STA
CERT
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FAX ti � a �
SIZE
PERMIT TYPE ❑ ADDITION ARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR `�1 REMODELING
DESCRIBE WORK BEING DONE: �
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES �
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyi
❑ Aluminum
❑ Other
❑ HOUSE ONLY
�( HOUSE & GARAGE
❑ ATTACHED GARAGE
� DETACHED GARAGE
HEIGHT
, �y� 2
ATFM�`I ZIP J�i� /
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim l. Site Plan/Survey showing the existing structures
❑ 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
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �I �. L5 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ , C .001 times the total job valuation
$ Lb .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 ( )
$ l.� Make checks payable to: City of Fridley Attach
THIS IS AN APPLICAT[ON FOR A PERMIT-NOT VALID UNTIL PROCESSED
[ 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 applicatio • a permi d work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of 1 f�1 h' �e ' eview and approval of pl �L, �J
SIGNATURE OF APPLICANT v`� PRINT NAME !��% /70�� � DATE ���F v"�l�
APPROVAL INSPECTOR S URE