P - 48399Building
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763-572�-3604
763-502-4977 FAX
DATE /n :
SITE ADDRESS
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
� . r=r , �p/��
O OWNER
Permit No.:
Received By: / � ��
Date��: ���� � � � �
�
ADDRESS:_ J�iU�'d,S f��G.-L1%CITY �� �t�.j STATE��ZIP�
PHONE: � �/ -- '�C��'--D % ��n
NAME: 9C ill('.1/ U A-�rGtn ffr�^P ,(� i%oP-6'C Z..�.�
STATE LICENSE # b,�- LEAD CERT NUMBER
ADDRESS: �O D� ��,o CITY (�/%G�o11C� STATE��ZIP ,�(J
v�:..�
PROPERTY TYPE s�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCT[ON
PERMIT TYPE ❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �TJo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
FAX
SIZE
STORIES
❑ GARAGE/SHED �INDOWS
❑ ROOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
�EMODELING
¢�Gt!
1�:11��11;1
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS ��.,6uP.�ii'f
�fX4 ovz-y�Pew � 6' �a-F�o Dca�-
NUMBER OF
FT
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT(ON [NCLUDiNG 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 STfCKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�j (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $� f D �Or 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
$
$
$
��''
.,���ja
. �' �'
� � �
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 pavable to: Citv of Fridlev
Attach
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 ermit o k is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case w h 'ew and approval of plar_ys,._. j� %`� /� ��`� .�nl��
SIGNATURE OF APPLICANT PRINT NAME :,,J /A'U 1�,� �C//�iYU� DATE d'J"
APPROVAL INSPECTOR SIG ATU �—
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