P - 47786Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �Q � I ,� '� ` �
SITE ADDRESS _�_�
THIS APPLICANT [S:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
OWNER
YOUR E-MAIL ADDRESS R� p h � I � na.
❑CONTRACTOR
Permit No.: �-�' �1�`7vi
Received By:
Date R
G
PROPERTY OWNER/ NqME: PI�'�lL �/�}��
TENANT ppDRESS. ,�/�(q ���
� �fZ CITY_ j''(R(%�[.��i STATE�ZIP��
PHONE: �jl /� — . ,��jQ ,� /f1 �/�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME:
STATE LICENSE #
ADDRESS:
PHONE
1� SINGLE FAMILY/NEW CONSTRUCT]ON g
❑ TWO FAMILY/NEW CONSTRUCTION g
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�iMAINTENANCE/REPAIR ❑ REMODELING
�D CERT NLIM
CITY
FAX
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
❑�
DESCRIBE WORK BEING DONE: _N�iG+� "� (qN �7S � Ir}q�-D (aj j¢-/.ZJ�}-(n�
SIZE OF fMPROVEMENT i.RNrTU .,,.r,T., _ ___ __ __
ROOFING
NUMBER OF SQUARES _�_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWC
STATE ZIP
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 & PORCHES SUBMIT:
I. Site Plan/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.
Hi.L r r.�,� ,�x� KASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(OSING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TVPF
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$ c� �
$ � ��_
$
$
$
$
$
$
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)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach
THtS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED • V V
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 applicati r a permit 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 o�a rk which ires review and approval of pl n.
SIGNATURE OF APPLICANT PRINT NAME ��/ L(,. �� DATE Ge -- /�j— �(
APPROVAL INSPECTOR SIGNATURE
,�._�._..:::� - , . .. .