2011-00792Building
Inspections
763-572-3604
763-502-4977 FAX
DATE (p "_,.�( —
SITE ADDRESS �
TH[S APPLICANT IS
PROPERTY OWNER/
TE1�IANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
Permit No.: �� (; �� ����
RESIDENTIAL APPLICATION Received By: ' `
CITY OF FRIDLEY D���a� _
EFFECTIVE 1-1-201I
` YOUR E-MAIL ADDFtESS 1 M i{� 1�'1" /�i�"t�f'((�G.� '�t4 %'�.�
!'. An< <'► r- �` � t .
❑ OWNER
NAME: �
ADDRESS:��
PHONE:�
NAME: �
STATE LICENSE #
ADDRESS���+��
PHONE /a� /..� �
�CONTRACTOR
0
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ���❑,,,.,,,��rrrGARA(
❑ BASEMENT FINISH �ROOF
CITY
STA
EAD CERT NLJMBER
CITY�
F��l � ='�a� .
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ DECK SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODEL[NG
', DESCRIBE WORK BEING DONE:
! S[ZE OF [MPROVEMENT
ROOFING
NUMBER OF SQUARES �� ��
GARAGES �5�,�
PROPOSED SIZE: �
PROPOSED HEIGHT:
S DING
V inyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
�
�
HEIGHT
FT
❑ HOUSE ONLY `�]� '`� `
❑ HOUSE & GARAGE `'"���� � BASEMENT REMODELING SUBMIT:
�`�1r���'��/'�� ]. Existing Floor Plan
❑ ATTACHED GARAGE ��� 4 2. Proposed floor plan
❑ DETACHED GARAGE 3. List of structural members to be used
FOR NEW CONSTRUCT[ON fNCLUDING DECKS,
j�ISoffit .�DITIONS. & PORCHES SUBMIT:
� Trim }�(b � '` 1. Site Plan/Survey showing the existing structures
�il,Fascia � (.; `���`, and proposed project.
2. Two sets of construction plans
3. Energy Calculations
LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
NUMBER OF
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
I Permit Fee $ � z See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
�� Fire Surcharge $ /�- t� � .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ �j,�7� $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ , l' cf�— Make checks payable to: City of Fridley Attach Stinulations
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
a�pproved plan in the case���w�k�� equj����w and approval of ns.� �/`� /
GNATURE OF APPLICAN %� (�'/ PRINT NAM� C� � /�� � „�,� ;�� I
�nnnnvei TT�iCDG'fTl1D Oi/�7. n iron /'�'� � DATE