P - 46286Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� / �
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERM�T TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
E-MA
�� �� ���
r�'bWNER ❑CONTRACTOR
Permit No
Received By:
Da�d' � �
ADDRESS: �3 �.a �"'" �O C]TY /�l L� STATE��ZIP�
PHONE:_ip / aZ � �% % - �p�
NAME:
STATE LICENSE # LEAD CERT 1VUMBER
ADDRESS:
PHONE
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCT[ON
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING�
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGH'i:
SIDING
O Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENTNGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WTNDOW TO BE INSTALLED
..-
CITY
FAX
� ROOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
ATE ZIP
BASEMENT REMODELING SUBMIT:
I . Existing Fioor Pian
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT[ON (NCLUDING DECKS;
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WtNDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON W[NDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
AL 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
$ �3.ZS
$
$
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.00OS 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 ( )
checks payable to: City of Fridley Attach
THIS [S AN APPL[CATION FOR A'PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 acknowledge that the information above is comp}ete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridtey 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
approved plan in the case �,�,�ork w h requir s review and approval of p(ans. �
SIGNATURE OF APPLICAN'�� _/__ C ���� PRINT NAME DATE� -� % 2 0�
APPROVAL INSPECTOR SIGNATURE °'"