P - 43888Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� IO /�
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-09
YOUR E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
' � � •� �lQl►li///ii/L'/�1d
• �
STATE LICENSE
PHONE [P � :J /� J a.+/
SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH ,�.rROOF
❑ DECK ❑ SIDING
❑ SWIMM
�❑ W HOME CONSTRUCTION
INTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
CITY
EXP DATE
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
NG POOL
❑ ADDTTION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS DYes �No LOCATION OF WINDOWS
OR FOR NEW OPEIQINGS-DESCRIBE SIZE OF
OPENING CHANGES &
Permit No.:
Received By:
Date R� fi . '. '� � � �
BASEMENT REMODELING SUBMIT;
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDTTIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction pians
3. Energy Calculations
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION � OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ Irj,��_ See Back Page for Fee Schedule
$ 6S% of Building Permit Fee
$� .001 times the total job valuation
$ �— .0005 x Permit Valuation Minimum $.50
$ $5.00 (State Licensed Residential Contractors)
$ $2000 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$21=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Ageement necessary ( ) Non Necessary ( )
$ ,,�2.. Make checks uavable to: City of Fridlev Attac
THIS IS AN APPLICATION FOR A PERMTT-NOT VALID UNTIL PROCESSED
I hereby apply for a bnilding 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 accordance with the
approved plan in the case of work which re uires review and approval of plans.
SIGNATURE OF APPLICAN PRINT NAME /oJ�/"�J�/'Q/ �S�YP$. �� I
PLEASE NOTE: SEPARATE PERMITS ARE REOUIRED FOR PLUMBING, ELECTRICAL AND