P - 45204Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ( " �{ "
SITE ADDRESS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2011
THIS APPLiCANT IS: ❑ OWNER
PROPERTY OWNER/ l NAME:�
TENANT
ADDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
YOUR E-MAIL ADDRESS
L���i
,13 �,r ✓�:fi� �� �
CiTY
Permit N
Received By:
Date Rec'd:
A
STATE LICENSE # � [� �j � % � '7 � LEAD CERT NLIMBER
ADDRESS ;���j,jlYt,, !yj ) �-GIYL °(_ C(TY L: i�l l.� ���+5 .ST�ATE%�ZIPSJ v�
0
FAX i%� !
❑ 5iNGLE FAMILY/NEW CONSTRUC7`ION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WMDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TII,E
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
� NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODEGING
ROOFING
NUMBER OF SQUARES � �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Afuminum
❑ Other
WINDOWS
IN EXISTING OPEi1INGS ❑Yes �No
OR FOR NEW OPENiNGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BB INSTALLED
� HOUSE ONLY
❑ H E & GARAGE
Ll ATTACHED GARAGE
� DETACHED GARAGE
❑Soffi[
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HEIGHT
FT
BASEMENT REMOQELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site PIan/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)
COTAL JOB VALUATION $���a 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
$ �/r � s See Back Page for Fee Schedufe
$ —'�� 65% of Building Permit Fee
$ �. .001 times the total job valuation
$ 7 .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 payable to: City of Fridley Attach
ns
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and t 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 Pridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work ' not to start without a permit on site; that the work will be in accordance with the
approved plan in the case ork whi equi es view and approval of pla . /
SIGNATURE OF APPLICANT � PRINT NAME �'`�Gy,/�� �LCl Z'�— DATE �"�i �' 6�
APPROVAL INSPECTOR SIG AT E t .�