P - 48149Building
Inspections
763-572-3604
763-502-4977 FAX
DATE��
SITE ADDRESS G
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THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERNIIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 11-2011
YOUR E-MAIL ADDRESS
Sfi ��
❑ OWNER
NAME: T�1' � 1► iLC�"IlU �
STATE LICENSE # LEAD CERT NUMBER
ONESS.��Ci �p,C�Q N CITY,�
O F,v� (.! � �
INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FII�IISH ROOF ❑ DRAIN TILE
❑ DECK SIDING ❑ OTI�R
SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR- . ❑ REMODELING
ROOFING n �
NUMBER OF SQUARES C%�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
�-IOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
WIDTH HEIGHT
s Vmyl I� S j � U� (�� e�`�offit SIDING/SOFFIT/FASCIA
❑ Aluminum �� � J �� �" l Trim REMOVED? ❑ YES 0 NO
❑ Other �S� `� Fascia
WINDOWS
IN EXISTING OPEI�IINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES 8c
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
Permit No
Received By;
�-o
STAT� ZIP,.� �a
FT
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 structures
and proposed pmject
2. Two sets ofconstruction 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) ,/
TOTAL JOB VALUATION �> r 3, A��i9 OCCUPANCY 5 I Y�Q �P TYPE -t'(:1
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
i ��
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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$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks navable 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 cod of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an appli tio for a pe it and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the ca o o h r uires review and proval of �s.; _ (�
SIGNATURE OF APPLIC PRINT NAME��/ (d DATE I Z� � G�� I
APPROVALINSPECTORS