P - 35078Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � ._i
S[TE ADDRESS C�l O
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
❑ OWNER
PROPERTY OWNER/ NAME:
TENANT `
ADDRESS:
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSUR.ANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEiNG D
SIZE OF [MPROVEMENT
STATE
CITY OF FRIDLEY
EFFECTIVE I-1-2011
YOUR E-MAIL ADDRESS
�T
�
�[o � "'
f0 ' . � C1 / °. � /G �-
INGLE FAMILYMEW CONSTRUCTION
TWO FAMILYMEW CONSTRUCTION
� BASEMENT FINISH ROOF
❑ DECK SIDING
❑ SWIMMING POOL
Permit No.: �-�i
Received By:
� . :;���1' - - '��
ATE�%�/1%LiP�
EAD CERT NUMBER
CITY 4 STATE�fP ^330
FAx ��3 - a(a7 -- 70��
SIZE
STORtES
❑ WINDOWS
� DRAIN TILE
❑ OTHER
❑ NEW HOME CONSTRUCTION 0�9HITION
❑ MAINTENANCE/REPAIR , ��7 REMODELING
ROOFING / �
NUMBER OF SQUARES [
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
� Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
�
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION (NCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim L Site Plan/Survey showing the existing structuros
and proposed project.
❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes ❑No LOCATION OF WtNDOWS 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 WMDOWS '
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
!J �THE 1997 U.B.0 FEE SCHEDULE)
fOTAL JOB VALUATION $ 7" r� OCCUPANCY TYPE
Permif Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
iYs�
1�
�:
IYI
See $�ck Page for Fee Schedule
65% of Building Permit Fee
.00l times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$3.00 (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 oavable to: Citv of Fridlev
Attach Sti
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appty for a buitding 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 Fri and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application pe i i o start without a permit on site; that the work will be in accordance with the
approved plan in the case all w ' w and a of pla s. /� /�
SIGNATURE OF APPLICANT PRINT NAME ���1� �'J�(/� S DATE � l� //