P - 42196Building
Inspections
763-572-3604
763-502-4977 FAX
DATE '•T_l
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYl'E OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
l�l ,�' f",
❑ OWNER �CONTRACTOR
NAME: � �
ann�ss: — � � �
PHONE: � �
NAME:�J�'
STATE LICENS #
ADDRESS:
PHONE , ` �
SINGLE FAMILY/NEW CONSTRUCTION
O� LY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGF/SHED
❑ BASEMENT FINISH ,�ROOF
❑ DECK ❑ SIDING
DESCRIBE VJORK BEING DONE:
SJZE OF IMPROVEMENT -
�B�F.R OF SQUARE h �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑
HOME CONSTRUCTION
EAD CERT NUMBER
J
CITY
FAX `C
SIZE
STORIES
❑ WINDOWS
O DRAIN TILE
Q OTf�R
NG POOL
❑ ADDTfION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE 8c GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
Permit No.:
�- - -, : �1..�
�.,, , �� � � �
3� �► _
BASEMENT REMO,AELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of sfiict�ual members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
�Soffit ADDTI'IONS. & PORCHES SUBMIT:
❑ Trim 1. Site Placi/Survey showing the existing structwes
Q Fascia a°d ProPo�d P%I�-
2. Two sets of wnsWction plans
wnvnows 3. Energy Calculahons
IN EXISTING OPENINGS DYes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 199� U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Cwb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �� /S See Back Page for Fee Schedule
$ �"- 65% of Building Permit Fee
$ .001 times the totai 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 navable to: Citv of Fridlev Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowiedge 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 accordance with the
appmved plan in the case o w �hi u' review and approval of pl S� �-.] ( (
SIGNATURE OF APPLICAN O�� PRINT NAME y�L(. �/ �ATE ���J I
wnnn�vwi T.TOUCl�T/1D CT _ T! ro� -�
__. ___.. . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . .. . .
PLEASE NOTE: SEPARA.TE PERMITS ARE REQUIRED FOR PLiJMBING, ELECTRICAL AAtD MECHANICAL WQRK