P - 42742Building
Inspections
763-572-3604
763-502-4977 FAX
DATE -a v l
SITE ADDRESS lV
THIS APPLICANT IS:
�
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
PROPERTY OWNER/ I N,�:_
TENANT �DRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
STATE LICENSE #
ADDRESS:�1�' YJ�12�� � '
PHONE
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
PERMIT TYPE ❑ �DITION ❑ GARAG
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION �
'" �'MAINTENANCE/REPAIR
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
CITY
Permit No.
Received By:
Date Rec'd:
TATE ZIP
EXP DATE
' CITY l
FAX
SIZE
STORIES
i/SHED INDOWS
❑ DRAIN TILE
❑ OTHER
[�IG POOL
❑ ADDITION
❑ REMODELING
i .+�l �
l7l/TT1T[.i lil' LI�il:i7T �C / � �,
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS- SCRIBE SIZE OF
OPENING CHANGES & ]� ��i �J
TYPE OF WINDOW TO BE INSTALLED r<<�"�--° �� NUMBER OF WINDOWS _,L-�
,aocc
STATE lL/�{�ZIP S��-
F'I'
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing stxuctures
and proposed project.
2. Two sets of construction 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)
CAL JOB VALUATION $��� ' OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
' Sewer Main Charge
I� Total Due
$ �� �!,j rj 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)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ rj �. Make checks payable to: Cityo uf 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 Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for permit and w s not to start without a permit on site; that the work will be �ln accordance with the
approved plan in the case of a ork which es rev' and approval of p�1 s. j' %� �J /
SIGNATURE OF APPLICANT PRINT NAMEf�p Sr �',i�-x��c a�d/1 ct - DATE l�(•�/v
APPROVAL INSPECTOR SI A Y °�—'