P - 42367Buil�in�
Inspections
763-572-3604
763-502-4977 FAX
DATE� X� I
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
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
EFFEC7'IVE 1-1-2010
YOUR E-MAIL
_ v� �_ NY. �t-�
❑ OWNER NTRACTOR
NAME: �' -F- a�
ADDRESS: � �' � I
PHONE: � ' V
NAME: G �
STATE LICENSE #
ADDRESS:� . L
$SdNGLE FAMILY/NEW CONSTRUCTION
O TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH O ROOF
❑ DECK ❑ SIDING
❑ SWIMM
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
R OFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS es ONo
OR FOR NEW OPENING -DESCRIBE
Q HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
EXP DATE
��CITY`�
FAX d� � �
SIZE
STORIES
INDOWS
�� DRAIN TILE
❑ OTHER
G
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BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS_ & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing struciures
❑ Fascia and proposed project.
2. Two sets of construction plans
3. Energy Calculations
.TIO OF W D_0�.� .('1 FOR WINDOWS — PROVIDE U-VALUE AND
'��__ _ �v __ MANUFACTURE STICKER ON WINDOW.
ITYPE OF WINDOW TO BE INSTALLEDV�N�� NUMBER OF WINDOWS � I
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�j LIJSING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $� L��� 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
$ d .001 times the total job valuation
$ � .0005 x Permit Valuation Minimum $.50
$ �C� $5.00 (State Licensed Residential Contractors)
$ � $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ ,� , Q Make checks pa_yable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D LINTIL 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 ord' c an codes of the City of Fridley and with the Min sota Construction Codes; that I understand this is not a
permit but only an appli tion r a rmit and work is not to start without a permi on site; that the work will be i acco ance with the
approved plan in the case w r w ich eyuires review and approval of pl
� �
SIGNATURE OF APPLICANT PRINT NAME�� � �'��� DATE � ��