P - 35788Building
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
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDItESS
�. � . .
❑ OWNER �NTRACTOR
NAME:
PHONE: �� ��^ C�� ^ RC�L'�
STATE LICENSE #
ADDRESS: I �I�
PROPERTY TYPE �TiNGLE FAMILY/NEW CONSTRUCTION
O TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ ADDITION
❑ BASEMENT FINISH
� DECK
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE_OF IMPROVEMENT_
,�OOF
❑ SIDING
❑ SWIMM
❑ NEW HOME CONSTRUCTION
� MAINTENANCE/REPAIR
,. 1f'2 — �o-�
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ Aluminum
� Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
CITY
Permit No.: �
Received By: �
Date Rec'd: —1
STATE�ZIP_
���\�
i,
CERT NUMBER
CITY P�Cl1��WC� STATE�ZfPSS3id�
FAX �'/.�� — 2S3'id�1
S[ZE
STORIES
� WINDOWS
❑ DRAIN TILE
❑ OTHER
NG POOL
❑ ADDITION � Y',Q—
❑ REMODELING
LENGTH WiDTH
❑ HOUSE ONLY
�OUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
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:
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction 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 MATERI.
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL 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
Total Due
7�
$ �
� �v —
$ c5
$ 5 _f� '
$
$
$
$
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 aavable 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 codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application pe it and worl ' t to start without a permit on site; that the work will be in accordance with the
approved plan in the case of wor ic u' • vi proval of plan1�'� ]/ ^ e
SIGNATURE OF APPLICANT PRiNT NAME 1<vp I� Q.�PIto„!� DATE � s� O—� �
ennnnvet mm�r.nmr�n nrnw�. .� w I7w _ �