P - 45274�
Building "
Inspecti�ns
� 763-572-3604
763-502-4977 FAX
' DATE ( U " � � �'
SITE ADDRESS �� �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
-
� �� , `�
BUILDING Permit No.:�_
RESIDEN�IAL APPLICATION Received By:— �=s—""�
CITY OF FRIDLEY �����:��
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
O OWNER �CONTRACTOR
NAME: �
ADDRESS:
- �J �a� � �..���
d'f � CITY
CONTRACTOR tvnl�tE: ��r.tE��r�r"tl?� J�����7�.-�-�.A� .�y7� ,
SUBMIT A COPY OF
YOUR STATE-LICENSE STATE LICENSE # l�� LEAD CERT NUMBEF
AND CERTIFICA'TE OF ADDRESS: '`i ��� �+.,�r� O�. CITY�
INSURANCE pHONE CQ,.�� - %� -�(� � FAX
PROPERTY TYPE �SINGLE FAMILY SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERNIIT TYPE ❑ ADDITION ❑ GARAGE/SHED DOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: 0 NEW HOME CONSTRUCTION ❑ ADDITION
�AINT$NANCE/REPAIR ❑ REMODELT,NG
DESCRIBE WORK BEING
� . ROOFING
- NUMBER OF SQUARES
� GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
wn�mows '
IN EXISTING OPENINGS �es ONo
f3R FCi N��'I OPE*IIN�^-�5- kSCIL'x3E SIZE OF
OPENING CHANGES &
WIDTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim �
O Fascia
LO�TION OF WINDOWS
�
STATE `�� ZIP �� �G�
07 `1 ' l
� STATE/�'I ZIP �r` ��L�
FT
BASEMENT REMODELING SUBMIT•
]. 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 sisuctures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
1vlANUFA(:TURE STI(;KER 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
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
(USING THE 1997 U.B.0 FEE 5CHEDULE) �
I �o� ( . OCCUPANCY TYPE
$ �GJ See Back Page for Fee Schedule
$ 65% of Bnilding Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ 5 $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ '] Make checks paysble to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID iTNT1L PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work witl be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota ConsUuction Codes; that I understand this is not a
permit but only an application for a ermit 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 1w rk�l ic require, review and approval of nlans.J�/ l /
SIGNATURE OF APPLICANT T ,-� �_pRiNT NAME f-� Y/,( C�f%/Y DATE �Q ��/ _�/
APPROVAL INSPECTOR SIGNATURE '
�L�A��!�F4TE: SEFARAT .�� '` ARE:�T�i�F��t�R. P.i.;i��,tc'ti �i. �[�T�z=�rn,�: ,at�r:i:£ivr�r��:��.c�nT.;;;�ur�,rt-i�"-'