P - 36742Building
Inspections
763-572-3604
763-502-4977 FAX
DATE� ��D I i
SITE ADDRESS �
THIS APPLICANT IS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:� ( � � �'Jt��j
Received By: ✓v �.w�
Dat��'��� � � ����
YOUR E-MAIL ADDRESS �% C� �!✓).�1 P,$Q�j��(�D��Kq ,� C,.�-�
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❑ OWNER .'�(`ONTRACTOR
PROPERTY OWNER/ Nq�g: �Cr,�Yr� �jf�J �
TEIVANT ,e,DDRESS: �% � % Gv��!►, ;, , fa� S�'/(�CITY
PHONE:_�I'<S`I a�" S�Q �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
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STATE LICENSE #
ADDRESS: �y%I
�
��� i� STATE�ZIP
,D CERT NUMBER
CiTY��G/q„(J STATE�IP
FAX
PROPERTY TYPE �-BiNGLE FAMILY/NEW CONSTRUCTION S[ZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE ❑�DITION ❑ GARAGE/SHED � WINDOWS
❑ BASEMENT FINISH �'ROOF . ❑ DRAIN TILE
❑ DECK ❑ SIDING � OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION � ADDiTION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE; I��
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PR�POSED HEIGHT:
SIDING
❑ Viny►
❑ Al�minum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WtNDOW TO BE INSTALLED NUMBER OF WINDOWS �
ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
�nF% . �C� OCCUPANCY TYPE
ocr�
❑ HOUSE ONLY
�[iOUSE & GARAGE
� ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
ALL FEES ARE
TOTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
vrd��
BASEMENT REMODELING SUBMIT:
i. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION (NCLUDING 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 WITlDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
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L
1
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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 aavable to: Citv of Fridlev Attach
THIS [S 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 and work is not to start without a permit on site; that the work witl be in accordance with the
approved plan in the case of a ork which requires review and approval of pl n�.
SIGNATURE OF APPLiCANT ,a;6%���.� PRINT NAME�i� S�vd P DATE �� I �— 1(
APPROVAL INSPECTOR SIGN.�TURE `