P - 48458Build,ing
Insp�ctions
763�572-3604 '
763-502-4977_FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE T l� � �
SITE ADDRESS " �.
THIS APPLICANT IS: �OWNER
PROPERTY OWNER/ NAME:�
TENANT e,DDRESS:
PHONE: (
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
S[ZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDI
myl
❑ Aluminum
❑ Other
YOUR E-MAIL AI�pjZESS
% L�, rJ (�i �' ,
J �
Permit No.: � �� —�
Received By:
Date Rec'd:�1 (D I
A
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: C[TY STATE ZIP
PHONE
FAX
�INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
� BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK �SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTtON ❑ ADDITION
❑ MAINTENANCE/REPAlR ❑ REMODELING
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED___
� HOUSE ONLY
❑ HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
O Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HEIGHT
FT
BASEMENT REMODELiNG SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDtNG DECKS,
ADDITIONS_ & PORCHES SUBMIT:
1. 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 WTNDOW.
_ __ __ -
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $_1?j Q�� 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
$ �' j See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ � r. .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$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � ` Make checks payable to: Citv of Fridlev Attach
lations
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 applicat' for a permit and ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o work w�ic e i review and ap roval of p ns. /�" •I / 7
SIGNATURE OF APPLICANT T NAME � q N i Ir t- `J ' t� ��/'�ATE �(D —�/
APPROVAL INSPECTOR SIGN TU v AA-P.G-.
����
_
CITYOF
FR[DLEY
FRIDLEY MUNICIPAL CENTER • 6431 UIVIVERSITY AVE. N.E. FRIDLEY, MN 55432 •(763) 571-3450 • FAX (763) 571-1287
BUILDING PERMIT APPLICANT: PROPERTY OWNER
� �� N � � � � � � �� �/1� understand that the State of Minnesota
,
requires that all residential building contractors, remodelers and roofers obtain a state
license unless they qualify for a specific exemption from the licensing requirements. As
the owner of the property at ���y' L�/ ,�,/� , Fridle.y, I
am exempt from the state licensing requirement nly if I am not building or improving
this property for purposes of resale. By signing this document, I attest to the fact that I
am improving this house for my own use and do not intend to sell it. I hereby claim to
be exempt from the state licensing requirements because 1 am not in the business of
building or remodeling on speculation or for resale and that the house for which I am
applying for this permit, isl the first residential structure I have built or improved in the
past 24 months. I also acknowledge that because I do not have a state license, I forFeit
any mechanic's fien rights to which I may otherwise have been entitled under Minn.
Stat. 514.01.
Furthermore, I acknowledge that I may be hiring independent contractors to perform
certain aspects of the construction or improvement of this house and f understand that
some of these contractors may be required to be licensed by the State of Minnesota. I
understand that unlicensed residential contracting, remodeling, and/or roofing activity is
a misdemeanor under Minnesota law, and that I would forteit my rights to
reimbursement from the Contractor's Recovery Fund in the event that any contractors I
hire are unlicensed. '
I have also been informed and acknowledge that by listing myself as the contractor for
this project, I alone will be responsible to the City of Fridley for compliance with all
applicable building codes and city ordinances in connection with the work being
performed on this property.
Name
Date �r c� < i