P - 41795Building
Inspections
763-572-3604
763-502-4977 FAX
DATE '��-P•l
SITE ADDRESS G
THIS APPLICANT TS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE ]-1-2011
O OWNER �eNTRA
i
NAME:
ADDRESS: 9 W
PHONE: / �o�! .� �II"'
NAME: �
STATE LICENSE � �%�
O'SINGLE FAMILY
❑ TWO FAMILY/NEW CONSTRUCTION
O ADDITION ❑ GARAG
� BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
CITY
� � LEAD CERT
�� z�
Permit No .c ' '
Received By:
Date Rec'd: � , //
STAT�ZIP�
�� � flT-.�o� � -/
;IT��/1W ��� STAT��! ZIPS DI
FAX (o SI 7 S 3- 9d 5d
SIZE
STORIES
❑ DRAIN TILE
O OTHER
❑ SWIMMING POOL
� TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE: —LLt} �
- SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT
ROOFING ❑ HOUSE ONLY
�
NUMBER OF SQUARES O HOUSE & GARAGE BASEMENT REMODELING S 1RA�iiT•
l. Existing Floor Plan
GARAGES O ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: O DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
IDIN FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl �Soffit ADDITIONS. & PORCHES SUBMIT•
O Aluminum � Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of eonstruction plans
WINDOWS 3. Energy Calculations
IN EXISTING dPENING3 �lYes ❑No LOC�4TION OF WIN OWS � FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF [JV� 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:
SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �, DO •"6 OCCUPANCY TYPF.
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Dne
$ y%. at- 5 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ 3. .001 times the total job valuation
$ % .0005 x Permit Valuation Minimum $5.00
$ •b D $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $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
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 applica ' n for a permit and w r is not to start without a permit on site; t at the work will be in accardance with the
approved plan in the case of al c hic quir s v' w an approval of plan� l� pATE �•�(.(� '��
SIGNATURE OF APPLICAN PRINT NAME
APPROVAL INSPECTOR S1GNA