P - 46257Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE I YOUR E-MAIL ADDRESS
SITE ADDRESS � ��� 1
THIS APPLICANT IS: OWNER ❑CONTRAGTOR
PROPERTY OW1vER/ NAME:
TENANT ____
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT
TYPE OF WORK:
DESCRIBE WORK BEING
�
PHONE:��i ����'� 2 [ IS
Permit No.:
Received By
Date Rec'd: _
'�1C� i I7 LCi STATE_/�/�ZIP � �
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: CITY STATE ZIP
PHONE pq}{
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
�'TWO FAMILY/NEW CONSTRUCTION STORIES
❑ BASEMENT FINISH
❑ DECK
❑ �iARAGE/SHED ❑ WINDOWS
[4''ROOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�SMAINTENANCE/REPAIR ❑ REMODELING
;:-9�l�ts u F� o � D i�o� P.�T �, n� �
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyi
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ j�IOUSE ONLY
Q�HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
wmTu
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:
1. Site Pian/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTLfRE. STICKER ON 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
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
J ��'
�"��
� ��
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See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the tota) 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 APPL[CATION 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 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 all work w ch re uires review and approval of p M�,,'�( I
SIGNATURE OF APPLTCANT��� �y� PRINT NAME �N L� 1' �-�'1 DATE � 12`3 I ��
APPROVAL INSPECTOR SIGNATURE