P - 47343Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS
THIS APPLICANT [S:
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 1-1-2011
YOUR E-MAIL ADDRESS
� �� � _-e �i
❑ OWNER �O1�qCTOR
Ess: � �'/
CITY �'►` 1 tirr
NAME -�.•J°L„° (�Cj.rC
STATE LICENSyE �#� �
ADDRESS: 7 ,� �
YHOI�,F (p L �f �j- ���L
�lSR�fGLE FAMILY/NEW CONSTRUCTI�
❑ TWO FAMILYMEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
SIZE OF IMPR(�VRivTF�tT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
C r�'� �'r'�
� �% LEAD CERT
7�,�.
�_ FAX �e
❑ SIDING
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATtON OF WINDOWS
NUMBER OF WINDOWS
W IDTH
❑ DRAIN TILE
❑ OTHER
v C�I
� HE
BASEMI
1.
2.
3.
Permit No.: ��� � ��i� ��-�'�
Received By:
Date Rec��� ,
STA
A
� rJ
FT �
Exis[ing Floor Plan
Proposed floor plan
List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDiNG DECKS,
ADD]TIONS & PORCHES SUBMIT:
1. 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.
tiLL r �.�J Axr; tsA51:ll ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY �rvn�
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ,
$
$
$
$ �j
$
$
$
$
$
$ ,
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 payable to: City of Fridle Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED r
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 ap 'cation for pe ' wor,� not;to start without permit on site; that the work will be in ccordance with the
approved plan in the cas of all wo w ich require eview and approval of pl s.
SIGNATURE OF APPLIC T PRI�JT NAM � ` "
APPROVAL INSPE OR SIG U E DATE
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