P - 37426Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �.J I c� nZ I a� �
SITE ADDRESS �rJ
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
Permit No.: ���
Received By:
CITY OF FRIDLEY Date ��:���t�� �
EFFECTIVE 1-1-2011
_ YOUR E-MA1L ADDRESS i�� K-1��� {1 I �j �� �-(�� �(����}`Q(,{ ' �,.(� �} ; �� ��
i"� � ., ( .,
❑ OWNER �ONTRACTOR
PROPERTY OWNER/ I NAME:�
TENANT
ADDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZ6 OF [MAROVEMENT
N�E:�C1 C�.�n��c�c,i�;�� �.�,�
CITY
ATE '9� ZIP
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: �--[�(� �iC��Y� �.C'A�k Ivf:. CITY�Sfi ��Y�IR.I STATE�ZIP
PHONEI.�Ic�—vl��"�I�1e3. FAX lB�c�.^���:7""����
C7 SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION O GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRA1N TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOI,
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �EMODEL[NG
ROOFING
NUMBER OF SQUARES �� �_
GATiAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyi
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE STZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
LENGTH
�.HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HEIGHT
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,
ADDITIONS. 8c PORCHES SUBMIT:
1. Site P(an/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
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
$
$ � �
$ 1
$ SL�.
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job vaivation
.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 oavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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 City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application fo ermit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case ' es 'ew nd approval of an�.,,(,,� `/ � _
SlGNATURE OF APPLIC PRINT NAM�� +�' "`'�' 1�-t� �� DATE 4� I°�'L,,°�� �
APPROVAL INSPECTOR SIGNATURE r—