P - 35967Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS
THIS APPLICANT IS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT[VE 1-1-2011
❑ OWNER
PROPERTY OWNER/ I NAME�
TENANT
YOUR E-MA1L ADDRESS � �
CITY
CONTRACTOR N,v�,tE: ^w � �
SUBMIT A COPY OF STATE LICENSE # C� O LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �`'� CITY�
INSURANCE PHONE � � � � FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DITION ❑ ARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ROOF Q DRAIN TILE
❑ DECK SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ I1EW HOME CONSTRITCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRiBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
I PROPOSED HEIGHT:
! SIDING
! ❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTMG OPENINGS ❑Yes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
INSTALLED.
NUMBER
WtDTH
Permit No.:�( -�� � 5 � �
Received By:
Date Rec'd: � �
, C��rr��7orl�� . C u t`
STATE�G�.•�[P
�,-�STATE�Z�P S �,6
�l .� �'71R � /
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed Floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR W[NDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDII�IG THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $ � 0� THE 1997 U.B.0 FEE SCHEDULE)
OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surchazge $ .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
Total Due $ ���-� Make checks payable to: City of Fridley 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 and codes of the ity of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a pe 't d w k is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all r i c r re 'ew and approval of plans.
SIGNATURE OF APPLICANT PRiNT NAME DATE
2t S. �3