P - 47798Building
Inspections
763-572-3604
763-502-4977 FAX
DATE (,� ��
SITE ADDRESS FL
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
NAME:_ 1 i�`n C1 � fl s-}�r',�r —
ADDRESS:��.+,�'���-� ��
PHONE:
CITY
Permit No.:
Received By:
Date Rec'
STATE (�ZIP '�'-� �C�"�j?
' '� " " t'ic�Kls-cNuf�
STATE LICENSE # LEAD CERT NUMBER
ADDRESS:�� .�a� r"(�l0
CITY �r�oC STATE�ZIP SS Z
PHONE Z � �i ` '
❑ SINGLE FAMILY/NEW CONSTRUCTION F�
❑ TWO FAMILYMEW CONSTRUCTION eTZ,n.r�----
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
�1"MAINTENANCE/REPAIR
6�ROOF ,� ..���,�.�rv�
❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
O REMODELING
SIZE OF IMPROVEMENT
LENGTH WIDTH HEIGHT
ROOFING ❑ HOUSE ONLY SQ FT
NUMBER OF SQUARES _��_ BASEMENT REMODELING SUBMIT:
❑ HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE � Existing Floor Plan
, PROPOSED SIZE: ❑ DETACHED GARAGE 2 P�oposed floor plan
PROPOSED HEIGHT: 3. List of structural members to be used
SIDING
❑ Vinyl FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Aluminum ❑Soffit ADDITIONS & PORCHES SUBMIT:
❑ Other ❑ Trim I. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
WINDOWS . 2. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS 3 Energy Calculations
I OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS - PROVIDE U-VALUE AND
IOPENING CHANGES & MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED
NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $ �USING THE 1997 U.B.0 FEE SCHEDULE)
Permit Fee OCCUPANCY TVPF
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
�D �i .
$
$ - `�
$ 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)
�+6�— ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to• City of Fridley Attach
THIS IS AN AppLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED N��4������
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 for a e' a work is not to start without a permit on site; that the work will be in accordance with the
approved pian in e ase of ail work whic re uires review and approval of plans.
SIGNATURE OF AF��r��-eANT _ � . --
APPROVAL INSPR('T �r:�.i n-rt m�- 4���_PRINT NAME .,
C.�-�5