P - 46500Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /�
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
e - ; /`l
YOUR E-MAIL ADDRESS
� S� �i �
❑ OWNER
ADDRESS: `'�i���� CITY
PHONE: (�^ ����(j%C,�
Permit No.:� �' � ����
Received By: �,��
�. �- ,� � : , �-.
r �
v�
ATE��LIP.
CONTRACTOR NAME:1�s�Z� zs �:✓ �fi{ ��.sr� �.�-= c9,-�S
SUBMIT A COPY OF STATE LICENSE # o��i �(�-.�J � LEAD CERT NUMBER �� f i-� Gl3��S -,Z
YOUR STATE LICENSE 1�
AND CERTIFICATE OF ADDRESS: fOFfCx�� ���%' C_ l�- /.S- G> `�CITY � :ti. ��- STATE /�.�IP SSyr,.-�
INSURANCE PHO T��--=� i� %/ �� FAX % 3-�/' �--: S�cfSe/ 7
PROPERTY TYPE
PERMIT TYPE I ❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
,W CONSTRUCTION
CONSTRUCTION
❑ GARAGE/SHED
� $QOF
❑ SIDING
❑ SWIMMING POOL
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ,S� � c
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES � �I9USE & GARAGE
GARAGES �TACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
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:
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.
� TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
d (USI THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ O ��� 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
$
$
$ 1
$ J
$
$
$
$
$
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 pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply far a building permit and I acknowledge that the information above is complete and accurate; that the wark will be in
conformance with the ardinances 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 wark 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 or r es review and approval of plans. /( �///
SIGNATURE OF APPLICANT „i��'�J� PRINT NAME �S ��—t-, �-� DATE
APPROVAL INSPECTOR SIG URE