P - 42156Building
Inspections
763-572-3604
763-502-4977 F
DATE�SITE ADDRESS _
THIS APPLICANT I5:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YQUR E-MAIL ADDRESS
�� S� .i; I
❑ OWNER Q]�1TRACTOR
PROPERTY OWNER/ I NAME:_
TENANT pDDRESS:
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE #
AND CERTIFICATE OF ADDRESS:��
INSURANCE pHp� Q �
PROPERTY TYPE .8'SrMGLE FAMILY/NEW CONSTRU TIi
� TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BE1NG
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
CITY
Permit No.:
Received By:
Date Rec'd:
ATE ZIP,
CITY E�1� STATE I�11vZIP SIY 3�
SIZE
STORIES
i/SHED ❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
NG POOL
❑ ADDITION
p-R£MODELING
WIDTH
R OFING ��,�,�
NUMBER OF SQUARES T J 9
GARAGES T�
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
❑ Viny!
❑ Aluminum
❑ Other
O HOUSE ONLY
� HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
OSoffit
❑ Trim
❑ Fascia
WINDOWS
TN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE iNSTALLED NUMBER OF V
HEIGHT
BASEMENT REMODELING SUBMIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structutal members to be used
FOR NEW CONSTRUCTION 1NCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT•
1. Site Plan/Survey showing the existing swctures
and proposed project.
2. Two seu of construction pians
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)
COTAL 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 _
$
$ °I�j -
$ S
$ �
$
$
$
$
$ , o a. _
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)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: Citv of Fridlev Attach
lations
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 a permit and work is not to start without a permit on site; that the work will be in accor ance ith the
approved plan in the case of all worr1� whi res review and approval of plans. C,
SIGNATURE OF APPLICANT �/i'� �� PRINT NAME ��� c, I� d �1/�� �I�pATE � /
APPROVAL MSPECTOR SIGNATURE