P - 35257Buildin.g BUILDING Permit No.:�� � �� i�`� 1
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vat��``e'�dJI�L ��1�
763-502-4977 FAX EFFECTIVE I-1-2011
DATE /�� `` _ YOUR E-MAIL ADDRESS v��yN e�����v ��G . CO%1�
SITE ADDRESS �
TI-IIS APPLICAN'f IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERNIIT TYPE
h
STATE LICENSE
�D�SS: 9
0
PHONE `� f`i�U� '� l V C_
J�INGLE FAMILY/NEW CONSTRUCTION
�� TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FIAIISH 0 ROOF
❑ DECK � SIDING
❑ SWIMM
EAD CERT NUMBF�
CITY[�
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTEIER
TYPE OF WORK: W HOME CONSTRUCTION ❑ ADDITION
ENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � ( �
SIZE OF IMPROVEMENT LENG WIDTH
ROOFING r � � Y/w ❑ HOUSE ONLY
NUMBER OF SQUARES �J �• ❑ HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
❑�y1L � ❑Soffit
❑ Aluminum f � `�� � ❑ Trim
❑ Other � � ❑ Fascia
HEIGHT
Pilli
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FORNEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS, 8c PORCHES SUBMIT:
1. Site Plan/Survey showing the e�sting structures
and proposed project.
2. Two sets of construcrion plans
WINDOWS 3. Energy Calculations
IN EX[STING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPL�NINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
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 Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$ ��
$ 7 �0
$
$
$
$
$
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 pa_yable to: City of Fridley _ Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclaiowledge 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 perm't 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 r 'ch reqxires review and approval of pl / � �` �/� /
SIGNATURE OF APPLICANT PRINC NAME � Ll%7��Q,n / y%ZL�I DATE G! /
APPROVAL INSPECTOR SIG
T�7 � A CF?l�Tfl'f'F• AoR A PFRI�iTfTC A'RF. RR(li'1TRRn'F(]R PT:fiTMRTNCi_ EI;FCTRICAL AND MECHANICAL WORK .