P - 35774Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:
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DATE �^��— �O /� YOUR E-MAIL ADDRESS (� p 6 f�0 �a/�l �tl I p' yit�ioo .�r1s�1
SITE ADDRESS /� �/S�i/S /�ba9 y S, Al, F
TH[S APPLICANT IS: �OWNER ❑CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING D(
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
ADDRESS: �J ( i f�'!/SS/SSr p�a i ��
PHONE: � S�� � yt� oZ ^ SL'1 G. /
ATE�ZIP SS � 3 �.
STATE L(CENSE # LEAD CERT NUMBER
ADDRESS: CITY STATE ZIP
PHONE
LE FAMILY/NEW CONSTRUCTION
FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
NEW HOME CONSTRUCTION
SID[lVG
��nyl � �/�'
9 Aluminum 'T'
❑ Other
WINDOWS
iN EXISTING OPENMGS es No
OR FOR NEW OPENINGS- ESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED_�
FAX
❑ GARAGE/SHED 'I� WINDOWS
�i'ROOF ❑ DRAIN TILE
�S[DiNG ❑ OTHER
❑ SW[MMING POOL
❑ ADDITION
❑ REMODELING
.. e � .. .� —
❑ HOUSE ONLY
�I-IOUSE & GARAGE
❑ ATTACHED GARAGE
� DETACHED GARAGE
❑So�t ,/ � �
❑ Trim `700'' J
OFascia �j,����✓ W)X/Cd�'S
Ez
LOCATION OF WIN WS
�P�u� R�b�.�, �c4--�B.efi� 4 3 bal�;,,,, s
ALL FEES ARE BASED ON VALUA
COTAL 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
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FORNEW CONSTRUCTiON MCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing sVuctures
and proposed project.
2. Two seu of construction pians
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WtNDOW.
NUMBER OF WINDOWS
CI N, INCLUDING THE COST OF LABOR AND MATERIALS:
THE 1997 U.B.0 FEE SCHEDULE)
t OCCUPANCY TYPE
$ !-�5�( � LS
$
$
$
$
$
$
$
$
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 aavable to: Citv of Fridlev
Attach
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 odes of the City of Fridley and with the Minnesota Construction Cades; that I understand this is not a
permit but only an application f pe ' and work is not to start without a p�rmit on site; that the work will be in accardance with the
approved plan in the case of _ 1_ _ res review and approval of pla s.h ,,� � ��
SIGNATURE OF APPLIC PRINT NAME /G �E� �J_ � DATE I—�DI �