P - 35488Building
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
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MAIL ADD�SS
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❑ OWNER .82�TRACTOR
NAME:_y
ADDRESS:
C
�l�Yi�'
���w
Permit No.: �-'`' ► Y U I��-1'-1
Received By:
Date �c.*'�1': `� � � : �
CfTY r/ l C.i I"� � STATE 1?�i �LIP
ADDRESS: ENSE �13 �� L� ' h LEAD CERT C TMBE STAT�ZIP ✓
V�) VI 4
PHONE F,qX
8'SINGLE FAMILY/NEW CONSTRUCTION SIZE
� TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE I � �DiTION
�❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING j(
NUMBER OF SQUARES � (/
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Ottier
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR 13EW OPENIt�3GS-DESCRISE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
LJ GAKAGE/SHED ❑ WINDOWS
@-i�t16rF � ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
FT
BASEMENT REMODELING SUBMIT:
] . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDING 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 — PROVTDE 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)
'AL 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
$
$
$
$
$
$ .
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
Attsch
THIS IS 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 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 perrr►it 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 all w�'� �ch uires review and approval of pl 1�
SIGNATURE OF APPLICANT (!/�— � PRINT NAME �i � 1�`-- �J�'�'L DATE �' ^�� '"' � r
APPROVAL INSPECTOR SIGNAT� --T—