P - 39383Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �''% ' % -.. � �
SITE ADDRESS ___���
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMTT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF W ORK:
DESCRIBE WORK BBING
BUILDING
RESIDENTIAL APFLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
YOUR E-MAII, ADDRESS
❑ OWNF,R
NAME:
PHONE:�7/.� – X � `I " �� % � G' .
STATE LICENSE #
�D�ss: �S`l�
PHONE � �.� � " % c� 1 `' % % �% .� g
.fiCSINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STOF
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FIIVISH .,�OOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
��+M�t1INTOME CONSTRUCTION ❑ ADDITION
BNANCE/REPAIR _ ❑ REMODELING
ROOFING /
NUMBER OF SQUARES � Y�''
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminwn
❑ Other
❑ HOUSE ONLY
� HOUSE �@, GARAGE
❑ ATTAC$ED GARAGE
❑ DETACAED GARAGE
CERT NUMBER
CITY�!
ax �7��3-�
❑ DRAIN TILE
❑ OTHER
Permit No.:2.0
Received By:
Dat���i: c
�ffT—�J `j�_
_ TATE�Ip�
~Gr���
FT
BASEMENT REMODELING SUBMIT�
1. Existing Floor Plan
Z. Proposed floor plan
3. List of structural members to be used
�
FOR NEW CONSTRUCTTON INCLUDING DECKS,
❑Soffit �ADITIONS & PORC�4 STTRI��T•
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
W�OWg 2. Two sets of construction plans
IN EXISTING OPENIATGS ❑Yes pNo -�- ��'gy Calculations
LOCATION OF WINDOWS FOR WINDOWS – PROVIbE U-VALUE AND
OR FOR NEW OPENiNGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CFIANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WiNDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST QF LABOR AND MATERIAI,S:
_(USING TI� 1997 U.B.0 FEE SCHEDTTLE)
'OTAL JOB VALUATION $ �,:j �C . (�� n�rnrro,►�►T�•v ..._.��
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
� `'1 �• �- 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 (Staxe 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 paya6le to: City of Fridlev Attar
THIS IS AN PLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSID
I hereby apply for a building permit and I ackn wledge tha e information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the C of F' ey and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work ' o o start without a permit on site; that the work will be in accordance with the
approved plan in the case of al ork whic requires re� and approval of plans. –
SIGNATi7R,E OF APPLTCANT" pA� ��� �� j��� �y ��
APPROVAL INSPF.CT(�R cTrrrnTrmF 07'J`i _—� � f J DATE _ % �%