P - 45769Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/
TE1�IANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
' TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER ❑CONTRACTOR
ADDRESS: Sy ZD S�" S�' CITY
NAME: � rd. f'•}S vh�c,.� COV.� �.r.r��. � v's _ LC.L
Permit No.:�
Received By:
Date Rec'd:
ATE ZIP
STATE L[CENSE t# ZO �D J7� I�D LEAD CERT NLiMBER
ADDRESS: I y S�( 3 �,re, n.i- �} CITY I� i'ti L� �C STATE�LIP 5 S a�(
PHONE 7b3-��3-- lb5�l FAX
� SiNGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGEISHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
ROOFING t
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
OPENTNG CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
O Trim
� Fascia
LOCATION OF W[NDOWS
OF WINDOWS
WIDTH
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT[ON INCLUDING DECKS,
ADD[TIONS & PORCHES SUBMTT
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 ST{CKER 01�f 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 $ OCCUPANCY TYPE
I Permit Fee
! Plan Review
� Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ s"
$�o
$
"' � L
$
$
$
$
$ .�
$
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: Citv of Fridlev
Attach Stiaulations
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 a d c es of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f t and k is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of al w review and approval of plans.�y�
SIGNATURE OF APPLICANT PRiNT NAME �Tll,.a (�� DATE � � � ' � (
��� �
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