P - 39642Building
Inspections
763-5 - .,�
, 63-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
�
SITE ADDRESS �i�,/ ��S'�"/] �J J
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/ NpME:
TENANT . _�__
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE #
AND CERTIFICATE OF ADDRESS�
INSURANCE pHONE
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MAIL ADDFtESS
� �,��'�%-�I /�'� �
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PROPERTY TYPE I SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
CfTY
FAX
SIZE
STORIES
Permit No�� � �'�� ��-�
Received By: �
Date Rec'd: � � � �
A'
T NUMBER
_CTTY i�i�vvc� �% STATE �`�iPL�"��I
PERMIT TYPE ❑ .��DIT►oN ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �f_ROOF ❑ DRAIN TILE
❑ DECK �L'� SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR L�REMODELING �E
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �__
GARAGES
PROPOSED S1ZE:
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
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINI
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION RJCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMtT:
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.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
SING�'HE 1997 U.B.0 FEE SCHEDULE)
COTAL 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 Chazge
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 Residential Contractors)
$2230 per SAC Unit (P(ans 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 Fridlev
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D 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 applica ' or ' and work is not to start without a p it on site; that the work will be in accordance with the
approved plan in th c of all ires review and approval of pl s.
SIGNATURE OF APPL PRiNT NAME_�S L� .+�.:t DATE �g %
APPROVAL INSPEC OR SI NAT