P - 45781Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-I-2011
Permit No.
Received By:
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DATE (y� � / � � � YOUR E-MAIL ADDRESS % rt',SC�P �Cc �.� < ' �C`Y.") -. C'�s2�
SITE ADDRESS �i� `�� f�/-a✓� 7v:�
THIS APPLICANT IS: ❑ OWNER l'�CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME: �'` K. �
ADDRESS: ��� I�rr� zci�
PHONE: �%jD�' j`�f(p� %G?_jCp
NAME:
CITY f�r���t� �/ STA
L. �-�
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STATE LICENSE #_ �L�"i�j J Ob � LEAD CERT NUMBER
ADDRESS: .%..,�C.%I �i 'L�+'� �°',UGv7i.� �,.��F� CITY�%tJHC�s'(/ i°Lc�$TATE�NGIPS-S %Z
PHONE ��'3 � 3�' / % /(,� FAX
� SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FiNISH
Q DECK
�=ROOF
❑ SIDING
❑ SWIMMING POOL
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
NEW HOME CONSTRUCTION ❑ ADDIT]ON
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:�
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES � �
GARAGES
PROPOSED SIZE:
PROPOSED I-IEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
1N EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
� HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffi[
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
WIDTH
FT
BASEMENT REMODELING SUBMIT:
I . 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.
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 Bscrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$ �
$
$
$
$
$
$ �-�
$ �I )lD .Y� �
See Back Page for Fee Schedule
65% of Buitding 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 �►ayable to: City of Fridtey Attach
THIS IS AN APPL�CATION 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 for 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 of 1 r ��c re �res review and approval of pl )
SIGNATURE OF APPLICANi'�il��/,.%� PRINT NAME _�5%n c,9 � l��ScGtt°ln�SG(�DATE ��%� / I
APPROVAL INSPECTOR SIG ATUIJ� RE