P - 48201Building
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:
� 1— Q�t �,� �z C�--�- � i -�—�-
._�r � : ;-/
BUILDING Permit No'�Z�a � �C� � � � z
RESIDENTIAL APPLICATION Received B� �
CITY OF FRIDLEY Dat��d: � N���� �(�'�
EFFECTIVE 1-1-2011
YOURE-MA►LADDRESS I����II �,� �� �- ��,�
❑ OW`PdER CO' TRAC
NAME: �
ADDRESS: ��� (�VL,(' � �
PHONE:���! �) -- �-}-�-I � �
NAME:
STATE LICENSE # /�L� L
ennuFCC� �<�� � �`� �
CITY
1
CERT N
PE�QNE ���1 _ -�- � l� . C � �1 1 ' FAX
NGLE FAMILY/NEW CONSTRUCT[ON SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRA[N TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�M� INTENANCE/REPAIR ❑ REMODELING
` ��
DESCRIBE WORK BEING DONE: �lC� �1V��C� �� V\� � Y� i� \ ll :'��C7 `'� ��� c' •
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS �s ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
WIDTH
STATE ZIP
- G -
�TAT��ZIP
�� ti t
BASEMENT REMODELING SUBMIT:
]. 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 �( ��'�\I I NUMBER OF WINDOWS �� �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
U�NG THE 1997 U.B.0 FEE SCHEDULE)
�" OCCUPANCY TYPE
� �' ,�. 5 See Back Page for Fee Schedule
$ 6�% of Building Permit Fee
$ �� .001 rimes the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ �,j �� � $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 ( )
$ ci�--�.[_[ �, Make checks navable to: City of Fridlev Attach
THIS IS AN APPUCATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit a I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and co e of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio for a pe it nd work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the c se of a, �c ' s 'ew and approval of plans. / � �
SIGNATURE OF APPLICA T PRINT NAME � f� �-�. DATE � �1.'I .
APPROVAL INSPECTOR SIG URE
PLEASE NOTE: SEPARATE P UIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK