P - 45814Building BUILDING Permit No.: �I � �' �%'t:�::r
Inspections RESIDENTIAL APPLICATION Rece���y: r
763-572-3604 � �
763-502-4977 FAX CITY OF FRIDLEY Date Rec'd:
EFFECTIVE 1-1-2011
DATE (�J � -�i � �� YOUR E-MAIL ADDRESS
S[TE ADDRESS �5r3 /,/, ti t. 5 S•"��. �5 f
THIS APPLTCANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
NAME:
ADDRESS:
PHONE:
NAME: �
�,r-c w.�! �l �eh.e
�
CITY
v �:
STATE ZIP
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: �� 5�I 3 �°-� ��- S� CITY �� L�ICt_ STATE�i� IP S.S�J'U
PHONE 7�3�- yy3 ��6 C/ �l FAX
SINGLE FAMILYINEW CONSi'RUCTION SIZE
❑ WO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION O GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN T]LE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MA]NTENANCE/REPAIR ❑ REMODELING
ROOFING ��
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS DYes ONo
OR FOR NEW OPENINGS-DESCRIBE STZE OF
OPENING CHANGES &
TYPE OF WMDOW TO BE IN5TALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
O Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
WIDTH
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT�
I. 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 Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$ 5 t�
$ ..
$
$
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 payable to: City of Fridley
Attach
THIS IS AN APPLICATION FOR A PERM►T-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 d codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio rmit d work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o k h' uires review and approval of p{aL� J � (19 Ol�i l�
SIGNATURE OF APPLICAN PRINT NAME dT�t DATE
APPROVAL INSPECTOR SIC'iNA URE