p - 47776Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:
Received By:
Dat�iad�d `�
DATE Co . , 3 - j (
YOUR E-MAIL ADDRESS
SITE ADDRESS
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/
TENANT N�E "� �--r�s,�
ADDRESS: �jltj �,�( �5,;,,` s�
CITY STATE Z[p
PHONE:
CONTRACTOR NAME: r�}S y�„�
SUBMIT A COPY OF G°`s ��-'�^-�- vs. ��C
YOUR STATE LICENSE STATE LICENSE # � O�G 37S f(p
AND CERTIFICATE OF ADDRESS: j�{ S�('j �„�� J� LEAD CERT NUMBER
INSURANCE PHONE (� �- y L('� ��C t,� CITY1.-�. .,. Cc Ia.-t STATE�ZIP .5 s3v �{
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION F�
❑ TWO FAMILY/NEW CONSTRUCTION S[ZE
PERMIT TYPE ❑ ADDITION ,� „,,, , ��,__ __ sTORrES —
❑ BASEMENT FINiSH """"c��n�,u
❑ DECK OOF
❑ SIDING
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ SWIMMING POOL
❑ MAINTENANCE/REPAIR � ADDITION
❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES 2 ,�
❑ HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑Soffit
❑ Trim
❑ Fascia
❑ DRAIN TILE
❑ OTHER
":"'n � SQ FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT(ON INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
WINDOWS 2. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS 3 Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS - PROV[DE U-VALUE AND
IOPENING CHANGES & 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:
TOTAL JOB VALUATION $ (USING THE 1997 U.B.0 FEE SCHEDULE)
Permit Fee OCCUPANCY TYPE
rian Keview
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �
$
$
$
$
$
$
$
$
See Rark Pµg� for Fee Schedule
65% of Building Pennit 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+6 ft= f�x$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks a able to: Cit of Fridle Attach Sti ulations
I hereb a 1 for a building permit ands acknowledge thORheP nformatoionvabo e is i ompletes nd accurate; that the wo
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conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that 1 understand this is not a
rk will be in
permit but only an application f r per ' 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 r �res review and approval of plan .
SIGNATURE OF APPLICANT ��� ��� P
APPROVAL INSPECTOR SI NATURE PRINT NAME DATE_ (��r,� " l�
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