P - 39643Building
Inspections
763-572-3604
763-502-4977 FAX
I DATE �'� � `�` r �
SITE ADDRESS
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
PROPERTY OWNER/ � NAME:
TENANT .-..._
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
Permit N� � �� � C
Received By•�
Date Rec'd:
YOUR E-MAIL ADDRESS Ir`M 0'►� �C�k 'r`� `�2 (�O (. GO,ti1
tw ��.J S �' A i�
.�..
a -1to - Co
NAME: N�-e /U���
STATE LICENSE #
ADDRESS: `-/ %�� t I W�� 1nS
❑
PHONE ��1�- SbO�b��� ,
INGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �ROOF
❑ DECK SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �YR�MODEL
C�TY
C.,
LEAD CERT NUMBEI
(1i � CiTY
F�c i 6�' ,!
SIZE
STORIES
❑ DRAIN TILE
❑ OTHER
NE]GHT
ATL�^"' ZIPSS^��2
� � ril� ` ���
��S STATE/L� ZIP :
—�Eo3�
FT
ROOFING �;,� ❑ HOUSE ONLY BASEMENT REMODELING SU$MIT:
NUMBER OF SQUARES/_ `' _�__ ❑ HOUSE & GARAGE 1. Existing Floor Plan
� �i
GARAGES Q ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION (NCLUDING DECKS,
❑ Vinyl ❑go�t ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim �. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS — PROVTDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF �vtAt�UFACTURE 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 $ 3, S C�O 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
$ � �.�. ,�b See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ � a .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 paVable to: City of FridleY Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D 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 witt► 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 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 all wor re ires review and approval of pla ,/� i r
SIGNATURE OF APPLICANT PRINT NAME ��-.. fY,l � S� � 7- DATE �� � ��' �
APPROVAL INSPECTOR SIGNATURE