P - 45007Building BUILDING Permit No.:���� ��"� (�
Inspections RESIDENTIAL APPLICATION Received By: 'r'�Y�r
763-572-3604 CITY OF FRIDLEY Date 1���� ^�i �
763-502-4977 FAX -��.
EFFECTIVE 1-I-2011
DATE �`� '� ��'� — �� YOUR E-MAIL ADDRESS C�:r��S�Y�M ��Z� l�S �✓�t i L(� .. �E' T
SITE ADDRESS L�'C'i �E'y�r�°!f G ��
THIS APPLICANT [S: ❑ OWNER L�ONTRACTOR
PROPERTY OWNER/ NqME: �1t
TENANT pDDRESS: G
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTTFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
STATE LICENSE
ADDRESS:
PHUN� l - dEJ — �
SINGLE FAMILY/I�iEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
O ADDITION
� BASEMENT FINISH
❑ DECK
R� ROOF
❑ SIDING
❑ SWIMMING POOL
STA'
�A1�
LEAD CERT NUMBER
CITY c�,�_S STATE ZIP,�s�i'Z!
FAX
SIZE
TYPE OF' WORK: ❑ NEW HOME CONSTRUCTlON ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �°
SIZE OF IMPROVEMENT LENGTH WiDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES � ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGNT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes DNo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
HEIGHT
F"f
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. 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)
TOTAL JOB VALUATION $ ��Y� `�" OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Contro]
Park Fee
Sewer Main Charge
Totat Due
$ o�( I - `L'S
$
$
$
$ 5
$
$
$
$
$
$ Cl�.�
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Pertnit 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 permit nd w k is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of al work wh�c res eview and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME Cc.ir"4' S�r�1���Z DATE � � aC) `�
APPROVAL INSPECTOR SIGNATURE