P - 39982Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATIUN
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
DATE___��
SITE ADDRESS � ��"
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/ NqME:
TENANT ,�DRESS:
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICBNSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
rY s�:t�-r,�<
YOUR E-MAIL ADDRESS
Permit No.:
Received By: � ' �'�''
Dat��4� dk:� �:.. � �. � � � � �
STATE ZIP
STATE LICENSE #___ �(j (o `� ���Q LEAD CERT NUMBER
ADDRESS: l �i �K Z ij�--..J C-� �U�' CITY /—�' � C� lc� STATE,�v�/LIP
PHONE �Ifo'�`. ��5-- IroS�'l FAX
k�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE � �DITION
❑ BASEMENT F►NISH
❑ DECK
TYPE OF WORK:
❑ GARAGE/SHED
OOF
❑ IDiNG
❑ SWIMMING POOL
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
L) NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING � —..�
NUMBER OF SQUARES __�_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Atuminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
WiDTH
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTfON fNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Srte PIan/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 VALUATI(3N, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $� d 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
$ �
$
$
$
$ �� —
$
$
$
$
$
$ ."
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 Residentiai 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 Fridley Attach
lations
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 appiication 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 f�� r qu�res review and approval ofP �ns.
SIGNATURE OF APPLICANT �' `� �.., PRINT NAME-�' 4°^[-�-t,�'� DATE �'� �' ��
APPROVAL INSPECTOR SI ATURE