P - 39630Building
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
/
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
Permit No..��l 1-o i L�
Received By:
Date Rec'd:
YOUR E-MA1L ADDRESS Lt1NGf ",�' _( -� A/l�D rriC7rr.�zdd5 LD�'1'1
OWNER �ONTRACTOR
NAME:
PHONE:
CITY
ATE ZIP.
NAME: f�E.2,�1 ��('7r"r.rC't'C�.0 � . .��tJG . -
STATE LICENSE # o7D�„ 3'�(o S-Li LEAD CERT NUMBER
ADDRESS: /�jt/D •-Jy,3cc` �f�o� �£ CITY STATE�IP 4 //
PHONE _ 7(r�.� `' 3.3 % �- /5�// FAX r/o 3 - �o'Zl� • - a �6 �
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
U ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �'ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE O� WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITfON
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
ROOFING
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENiNGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OAENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
� DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HEIGHT
FT
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.
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 Contro]
i Park Fee
� Sewer Main Charge
�: Total Due
$—�'65. -�S
$ �.�
_$ �.�
$ S'..C�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)
�+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: Citv of Fridlev
Attach
THIS [S 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 1 understand this is not a
permit but oniy 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 al w 'ch ires r an approval of plans �
SIGNATURE OF APPLIC I T NAME �iQnlC� �i2GQ'fiC�CE',r! DATE B o2
APPROVAL INSPECTOR TU ` �