P - 46636Building
Inspections
763-572-3604
763-502-4977 FAX
DATE : � '' / � � a� �
SITE ADDRESS S %O
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
; DESCRIBE WORK BEING
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MAIL ADDEtESS
� .t/,� Fr�
�?IOWNER �CONTRACTOR
ADDRESS: � % O .L ro �, �on S� ,�l/
PHONE: l�JG 3 J � os - yy� �
NAME: .�,
STATE LICENSE #
1
CERT NUMBER
Permit No.: � � �� a '`�j � �p
Received By:
��e�'°�:� �
ATE�ZIP �5��/.3oZ
CITY STATE ZIP,
PHONE FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
, ROOFING 'n
! NUMBER OF SQUARES��
; GARAGES
i PROPOSED SIZE:
' PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN 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
❑Sofiit
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF
HEIGHT
BASEMENT REMODELiNG SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to bc used
FOR NEW CONSTRUCTION MCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. 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 $ QCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ , .001 times the total job valuation
Surchazge $ �— .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ S�/ � 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 ihis 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 all w which re9ui s and approval of pl / J��� OI�
SIGNATURE OF APPLICANT PRINT NAME �a iy S/l�i�� DATE ��
APPROVAL INSPECTOR SIGNATURE
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