P - 46546Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS _
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 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER ❑CONTRACTOR
NAME: �ZJ�C�� \ .� --
ADDRESS:� yo'O 1A�1�, 7SO\� 1�'d
PHONE:�'�-�J'�� �� (,�
T
wten,r�• �i v�o,...�. � ._ .. �_ r�. _ _ �
STATE LICENSE
ADDRESS: � ��
PHONE% �3- �+aa-�►��
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
Permit No.:�
' - -• � �1�...
�
�. - � -� . � ,
: � �, . .
ATE�Z[P.
LEAD CERT NUMBER
Nu CITY �l ��� � C STATF� ZI�S 533�
FAx `-7103- �}��-40�"�
SIZE
❑ ADDTTION ❑ GARAGE/SHED ❑ W[NDOWS
❑ BASEMENT FINISH � ROOF ❑ DRAIN TILE
0 DECK ❑ SIDING ❑ OTHER
❑ SWIMMiNG POOL
❑ NEW HOME CONSTRUCTfON ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
,. ��ta c e `� `�'
ROOFING
', NUMBER OF SQUARES ��
i GARAGES
i PROPOSED SIZE:
' PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Othet
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WiNDOW TO BE MSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
OF
BASEMENT REMODELING SUBMIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTTON 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 – PROV(DE 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
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$_(%�'�� %, � See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ � C5� $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 ( )
� 0 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 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 all work hi uires review and approval o lans. \
SIGNATURE OF APPLICANT f� PRIN'£ NAM��� �b� DATE �i—�"��
APPROVAL INSPECTOR SIGNATURE