P - 39365Building
Inspections
763-572-3604
763-502-4977 FAX
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SITE ADDRESS
THIS APPLICANT IS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
Permit No.:�l/—
Received By:
Date Rec� ✓
YOUR $-MA1L ADDRESS {�,;�-p_ c/ j �� {��� /✓�/� � , �",> .'�I
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OWNER ❑CONTRACTOR
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PROPERTY OWNER/ NAME:��� OC.�rJn, l0 , il erv )
TENANT ppDRESS: ��j�,1 jA�!(e� 51 N� CITY -f�i,pC�j/ � STATE�jpLZIP��3G
PHONEi'�[.:� `� ) � 7 ��°i �3 �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
1NSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING DC
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
�Vinyl
❑ Aluminum
O Other
STATE LICENSE # LEAD CERT NUMBER
ADDRESS:
PHONE
❑ SINGLE FAMILYINEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
FAX
SIZE
STORIES
CTTY
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑�,R OOF ❑ DRAfN TILE
❑ DECK � SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTiON ❑ ADD1TfON
❑ MAINTENANCE/REPAIR ❑ REMODELING
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTAi.,LED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
WINDOWS
ATE ZIP
F'i'
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of struc!ural members to be used
FOR NEW CONSTRUCTION fNCLUDING 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 STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB �ALUATION $ ��'J OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Sarcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ��, � s�
$
$ � �
$ ��jZ�
$
$
$
$
$
$ �
$ , .
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
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I ac wledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the C of F'dley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f r a p it and work is t to start without a permit on site; that the work wil] be in accordance with the
approved plan in the case of al require ' w and approval of plans.
SIGNATURE OF APPLiCANT NAME e-��A�L DDNPcI �w»DATE O GI I��_���
APPROVAL INSPECTOR SIGNA A