P - 45837Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_ t r,�L
SITE ADDRESS �
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/ NAME:� rt
TENANT .����,,,,►.r,1
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
E-MAIL
�, _ .
STATE LICENSE # " {TOlQ i �_ V1le �
ADDRESS: W �'Y r��v
PHONE ��,Q �'." /"1 �` � "�
INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES =�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
,�ROOF
❑ SIDING
❑ SWIMM
Permit No
Received By:
Date Rec'd:
��T CITY�r��/11-�1// STA'
� �
�'�S�Y1� ?� }-
LEAD CERT NUMBER � 1 �
� CITY��G�,iY�,�I'
FAX �' N 1 -1 � �`7 ZZ
SIZE
STORIES
;/SHED ❑ WINDOWS
� ❑ DRAIN TILE
❑ OTHER
NG POOL
HOME CONSTRUCTION ❑ ADDITION
iTENANCE/REPAIR ❑ REMODELING
✓� "' � ,I
LENGTH WIDTH
�HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
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,
❑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 Calculat�ons
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW 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 $ , 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], /.�5 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 ( )
� . 1., 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 Conshuction 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 II y requires review and approval of lans. �,
SIGNATURE OF APPLICANT� PRINT NAME�I�tT_['( 4�S�ij�NtVl DATE�! Z� I I
APPROVAL INSPECTOR 5IGNA RE
PLEASE NOT�: SEPARATE PERMIT5 ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK