P - 40822Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
>s38.�,
Permit No.
Received By: C�
�DR� ' :
DATE 9��'�%� � YOUR E-MAIL ADDRESS �!'%/�Cy, ,/�/l,f'�„�qy� ������ 4� t,r n1�����.�_
sITE ADD�SS .,S"/p ..srern �?it c5`� �ll � �"-"
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ I NA�v1�:�
TENANT ADD�ss:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PHONE:��•- ��'Si'- �� �,S".
�E clrY 1cr��
TATE� iIP ��
STATE LICENSE #�`�/�����J� � LEAD CERT NUMBER I T- �� -
ADDRESS: 7 � CITY ST li'LG[� STATE�IP S/
PHONE ,fs,�/�- �J�S (JJ�'J,�`�'- FAX � Sf- 9os- �� ys"
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ Ga�GE/s�D wlNDOws
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMINGPOOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING
SI2E OF IMPROVEMENT
BOOIN'ING
NLTMBER OF SQUARES _
GARAGES
FROPOSED SIZE:
F'ROPOSED HEIGHT:
SIDING
❑ V inyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
FT
BASEMENT REMODELING SUBMIT�
1. Existing Floor Plan
2. Proposed floor plan
3. List of structtural members to be used
FOR NEW CONSTRUCTION INCLUDING ��ECKS,
❑Soffit ADDITIONS & PORCI3ES SUBMIT�
❑ Trim 1. Site Plan/Survey showing the existing structues
❑ Fascia and proposed project.
2. Two sets of canstruction plarns
WINDOWS 3. Energy Calculations
Lv EXISTING OPENINGS �Yes �No LOCATION OF WINDO S FOR WINDOWS - PROVIDE U-VALL�E AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF /�� y��"�� �'/lJ _ MANUFACTURE STICI�ER ON WIN��OW.
C�PENING CHANGES &
TY'PE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
U ING THE 1997 U.B.0 FEE SCHEDULE)
'�'�TAL JOB VALUATION $_ _� S OCCUPANCY TYPE
Fermit Fee
F'lan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Fark Fee
Sewer Main Charge
Total Due
$ I L7 Z`.S 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 Stipua�tions
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 wt�rk v✓ill be in
c��nformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
p�rmit but only an application for a ermit ork is not to start without a permit on site; that the work will be in accordance with the
a�proved plan in the case of all , ic r view and approva( of pla � � /,
S=GNATURE OF APPLICANT PRINT NAME ��� f/^,c/y��� DATE �I
APPROVAL INSPECTOR SIGN .