P - 39839Building
Inspections
763-572-36Q4
763-502-4977 FAX
DATE � � � "'`�
SITE ADDRESS � LS "'
THIS APPLICANT IS:
PROPERTY OWNERI
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑CONTRACTOR
PHONE: (, (o� �? ,5 ' / /"
CONTRA,CTOR NAME:_�
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE
AND CERTIFICATE OF ADDRESS:
INSURANCE pHONE
PROPERTY TYPE ❑ sirrGLE �.aMILYmiEw CorrsTxuCT�oN
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ ��tTtoN
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF 1MPROVEMENT
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
ROOFING �
NUMBER OF SQUARES �� �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Othet
WINDOWS
IN EXISTING OPENINGS ❑Yes QNo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
CITY
LEAD CERT NLJMBER
CITY
FAX
SIZE
STORIES
❑,.�'iARAGE/SHED ❑ WINDOWS
�'ROOF ❑ DRA[N TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING �
❑ }-IOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
L7 DETACHED GARAGE
❑Soffit
❑ Trim
O Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HEIGHT
Permit No.:
Received By:
Date R��dd�.�
ATE ZIP
STATE ZIP
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION [NCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
i. Site PfanlSurvey showing the existing structures
and proposed project.
2. Two sets of construction pians
3. Energy Calcu{ations
FOR WINDOWS — PROVIDE U-VALUE AAlD
MANUFACTURE ST[CKER 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
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
�' Park Fee
� Sewer Main Charge
�` Totaf Due
$ '� Gl .(��? See Back Page for Fee Schedule
$ 65°/a of Building Pennit Fee
$ «jG( .001 times the total job valuation
$ �j( � .00OS x Permit Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Gontractors)
$ $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 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 appiication for a permit and w rk is ot to start without a permit on site; that the work wi11 be in accordance with the
approved plan in the case of work whic � qu� �rev' w and approval of pl��` / � g �} �
SIGNATURE OF APPLICANT � PRINT NAME �"`-'�i(J ��� DATE �J � � ��
APPROVAL [NSPECTOR SIGNAT .�