P - 35071Building
Inspections
763-572-3604
763-502-4977 FAX
DATE .�i,��/ ✓
SITE ADDRESS �
TH[S APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
�
❑ OWNER
PROPERTY OWNER/ + NAME:
' TENANT I ___
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
1NSUR.ANCE
PHONE: � ✓ L
NAME: " J
STATE L[CENSE #
ADDRESS: �8 �
PHONE � � �
YOUR E-MAIL ADDRESS
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Permit No.:
Received By: �
Dat : 1 � r�.�,�--� �-� �
STA
�D CERT NLIMBER
CfTY� � � STAT ZIP
FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE I ❑ �DITION
❑ BASEMENT FINTSH
❑ DECK
TY.PE OF WORK: ❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRTBE WORK BEING
SIZE OF IMPROVEMENT_
ROOFING
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
� Vinyl
❑ Aluminum
❑ Other
WINDOWS
` M EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENIIJG CHANGES &
TYPE OF WiNDOW TO BE INSTALLED
❑ GARAGE/SHED ❑ WINDOWS
�1 ROOF ❑ DRAIN TILE
❑ SIDTNG ❑ OTHER
❑ SWIMMING POOL ..
� ADDITION /� e /j��Q
❑ REMODELING ( (/� �
HOUSE ONLY
HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER
SO FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
3
FOR NEW CONSTRUCTION MCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
L Site Pian/Survey showing the existing structures
and proposed project.
2. Two seu of construction pians
3. £nergy 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)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totat Due
$
$
$
$
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See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Va]uation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
$+6ft= ftx$25=$
$450 Conservation P(an Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: City of Fridlev
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D 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 ordinance d codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio a pe i an 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 a ork ' re ' r iew and approval of pl �s.�� /�� �{'��/ �, / �
SIGNATURE OF APPLICANT PRINT NAME ,/ (%�' �i r 6DATE U
APPROVAL INSPECTOR SIG U