P - 42193Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � , I')
S[TE ADDRESS _
THIS APPLICANT IS:
��
i PROPERTY OWNER/ I N
TF,NAI�TT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
0
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
❑ OWNER
�
ADDRESS
ADDRESS: CITY
STATE LICENSE # �
CERT
AlluKESS: � J J — CITY /
PHONE CB I� "�a � S — h 1� ftidf i�N/�a.b �
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH �'ROOF ❑ DRAIN TILE
❑ DECK �SIDING ❑ OTHER
❑ SWIMMING POOL
O NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/RF„PAIR � ❑ REMODELING ,
DESCt2IBE WORK BEING DONE:
ROOFING ,"�
NUMBER OF SQUARES (/ +
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
�' V inyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS�1'es �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENII�IG CHANGES & �
WIDTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHE AGE
���� a �a3
❑Soffit -- ---�_ .
❑ Trim
❑ Fascia
LOCATION OF WiNDOWS
.
Permit P���I�
Received By•
Date Rec'd• i
ATE ZIP
� STA
� ����
�Q�T
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING 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 WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED y,vv � NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
r (USING THE 199'7 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 Due
$ ��� �p`Z � See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �(% .001 times the total job valuation
$ 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 Pian Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ c, , Make checks payable to: City of Fridley 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 applicatio for a erm' d work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o ic ire review and approval of pl� ^y�/�
SIGNATURE OF APPLICAN � PRINT NAME �''��� �/�p,u�, /� IQ,S'�,l►_�DATE
APPROVAL INSPECTOR SI ATURE —T
�Y