P - 41202Building
Inspections
763-572-3604
763-502-4977 FAX
li DATE �� L � - �
SITE ADDRESS %ycJ
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
�. ' � .� t
�@'O �WNER
Permit No.: `'��' �S
Received By�.�''��'�
Date'l�e��''e1: � p � 01
YOUR E-MAIL ADDRESS � � ��C.V"'��" °j 5 � �� `J yG^�G`►� � � � J �^"
7�'
❑CONTRACTOR
PROPERTY OWNER/ NAME: )iiL� G�c1�„���
TENANT pDDRESS: 2- � 1 �� '�i %�//d -i �r CTTY /�!`� ciI Y y STATE_�ZIP
PHONE: bSl ` SS SS'" � �% �� �
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
ROOFING
NUMBER OF SQUARES Z �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
STATE LICENSE #
LEAD CERT NUMBER
ADDRESS: CiTY_
PHONE FAX
•�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES_L_
❑ ADDITION ❑� �G �AGE/SHED ❑ WINDOWS
❑ BASEMENT F[NISH ��ROOF ❑ DRAIN TILE
O DECK ❑ SIDING ❑ OTHER
❑ SWIMMtNG POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�CMAINTENANCE/REPAIR ❑ REMODELING
E: 1'C"f- � �l= �' �-c I �'� �`
TH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
ATE ZIP
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION [NCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim I. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE 1NSTALLED 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 $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Dae
$ j�i,S :�,,5 See Back Page far Fee Schedule
$ 65% of Building Permit Fee
$ �� .001 times the total job valuation
$ �j C� .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 ( )
$ 7. Make checks payable to: City of Fridley 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 Fridtey and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio�n,fer 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 1t�+l�rk which,,� ^re �uires review and approval of pl Gjr
SIGNATURE OF APPLICANT �` `�"� ``l - I� — PRINT NAME �< <� �"y� `� DATE / '� 2 p � � �