P - 46503Building
Inspections
763-572-3604
763-502-4977 FAX
I�TIU»I�L�
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE I-1-2011
YOUR E-MAIL ADDRESS � r(� �,E-
°'f..A /�/� C •P �
❑ OWNER �CONTRACTOR
ADDRESS: CITY
PHONE:
NAME:
.� �.LC
Permit No.:��l
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.r
� : - �;t � � 1 �
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STATE ZIP
STATE LICENSE # ZA�/�g0�77 LEAD CERT NUMBER
ADDRESS: '�"j 6� � �'�' Vv CITY U�x��+ STATE/n�ZIP �S��J�P
PHONE iDIZ— %�O'�9�S��I FAX 7— %t<<I S!�'Y
�jSINGLE FAMILY�G"C'6NSTIZU TION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
(� MAINTENANCE/REPAIR ❑ REMODELING
, DESCRIBE WORK BEING DONE: �.,r � p �-�pa
SIZE OF IMPROVEMENT LENGTN WIDTH
ROOFING ❑ HOUSE ONLY
' NUMBER OF SQUARES �? ❑ HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ DRAIN TILE
❑ OTHER
HEIGHT
I�1�
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT•
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
(N EXISTING OPENINGS ❑Yes ❑No C,OCATION OF WINDOWS FOR W[NDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WTNDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $����c�zC� _ 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
$
$
$
$ �
$
$
$
$
$
$ I i� . Infl
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 Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D 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
approved plan in the case of all�� w�hi,ch requires review and approval of plan�ry /
SIGNATURE OF APPLICANT C4��T— _ PRINT NAME ( a�e� �.�-f"P�`l`�r �— DATE //—%O Za( I
APPROVAL INSPECTOR SIGNATU—RE� �—