P - 36795Building
Inspections
763-572-3604
763-Sb2-49'77 FAX
DATE `—y7 �' 1 "J '�
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MA1L ADDRESS
❑ OWNER
NAME: 1� 1_1Y1.�, � i(A.iVV
ADDRESS: CITY
PHONE:
STATE LICENSE #
ADDRESS� D
PHONE �D �O� S I /
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ �DITION O GARAGE/SHED
❑ ASEMENT FINISH ❑ ROOF
ECK ❑ SIDING
❑ SWIMMING POOL
TYPE OF WORK:
DESCRIBE WORK BEING
OR OFING
NUMBER OF SQUARES ^
GARAGES
AROPOSED SIZE:
AROPOSED HETGHT:
' IDING
; ❑ Vinyl
❑ Aluminum
❑ Other
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �tEMODEL
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
O HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
OF WINDOWS
Permit No.: � � �"(} i'�l�w
Received By: ����
.:, � ;�� �,� _ ,
.
STATE ZIP.
CERT NUMBER
CITY �C� ��STATE�'vLI
__ _ ..., . . . � � �—�
FAX l (D.� `7'
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
F�
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of conswction 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 $ OCCUPANCY TYPE
Permit Fee
Plan Review
Pire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ Ld�L
$
$
$.
$
$
$
$
$
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 pavable to: Citv of Fridlev Attach
THIS IS AN APPL[CATION 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 applicati or � permit orlc �s not to start without a permit on site; that the work will be i accor ance with the
approved plan in the case of T hich re ' vi approval of p n��
SIGNATURE OF APPLICANT RINT NAME���IS �C.I C� �I ��l-o' DATE ��
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Layout dimension sheets are intended as a construction aid. Not all options selected are shown.