P - 45315Building
Inspections
763-572-3604
763-502-4977
DATE_ i
SITE ADDRESS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011 i ,
YOUR �-MAIL
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWIVER/ I N,�q�:�
TENANT
ADDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LtCENSE
AND CERTIFICATE OF
INSUR.ANCE
PROPERTY TYPE
PERMIT TYPE
0
Nan��:_��
STATE LICENSE #
PHONE r'�-r/..2 —
❑ SINGLE FAMILY/NEW CONSTRUCT]ON
I�'TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �"ROOF
❑ DECK ❑ SIDING
❑ SW[MM[NG POOL
CITY
CERT
i' CITY.�cm
FAX �.Z ��
SIZE
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
,�1"MAINTENANCE/REPAIR ❑ REMODELiNG
DESCRIBE WORK BEING DONE: -� — U
SIZE OF IMPROVEMENT Ln S'G% LENGTH WIDTH
ROOFING �d`HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE
GA GES ❑ ATTACHED GARAGE
PROPO SIZE: ❑ DETACHED GARAGE
P OSE EIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGBS &
TYPE OF WINDOW TO BE INSTALLED
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
❑ WTNDOWS
❑ DRAIN TILE
❑ OTHER
Permit No.;
Received By:�
Date Rec' d: � �1 � I�
STATEI�ZIP �� �
'ATE�LIP
FT
BASEMENT REMQDELING SUBMIT:
I . Existing Floor Plan
2. Proposed fioor pian
3. List of structural members to be used
FORNEW CONSTRUCTION TNCI.UDTNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu 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:
NG THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $�r� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Controt
Park Fee
Sewer Main Charge
Total Due
� �3 � a5 �
$
$ 2. �`7�
n
.
$ � �
$ �
$
$
$
$
� c c
See Back Page for Fee Sched�le
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $S.OQ
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6fr= ftx$25=$,
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: Citv of Fridlev Attach
ulations
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 ridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and rk is t to start without a permit on si ; t at he work will be in acc dance with the
approved pfan in the case of a r w�c�T re 'tir and approval of pl�, �
SIGNATURE OF APPLICAN NT NAME � � CS DATE
dPPAl1VAi R.1CPR('T(lA Cf(:1.fdT11DA
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