P - 48377Building s- BUIL�' ING Permit No��� "� g's�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY nate xec'd: �/
763-502-4977 FAX EFFECTNE 1-1-2011
DATE �i '/— l� YOUR E-MAIL ADDRESS �n�c�T�b� QLVjg'�/ C'�j'�
SITE ADDRESS � �D ��,�_��" J�C{,�p _ ��
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
OWNER ❑CONTRACTOR
NAME:
STATE LICENSE #
_CfTY�7'% / (
��3 3�0
CERT
ADDRESS: CITY.
PHONE
PROPERTY TYPE �I,SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT F(NISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR 1�,REMODEL
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENIIVG CHANGES &
TYPE OF WINDOW TO BE INSTALLED
O HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
OSoffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
FAX
SIZE
STORIES
STA
�l ��
� DRAM TILE' 1 /_-
�'OTHER ��jp(ndJ 4�/'
�/
�
ZIP �J l`'�
ATE ZIP
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT[ON INCLUDING DECKS,
ADDITIONS_ & PORCHES SUB�IIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu 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)
TOTAL JOB VALUATION $_�Q'� � OCCUPANCY TYPE
I Permit Fee
'�, Plan Review
'�, Fire Surcharge
Surcharge
' License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.U0
$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 aavable to: Citv of Fridlev
Attach
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 wili 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 •mit 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 ic u�r review and approval of plans.
SiGNATURE OF APPLICANT �f � PRMT NAME DATE
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