P - 35823Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � �1
SITE ADDRESS =
THIS APPLICANT IS
PROPERTY OWNER/
TE1�tANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE t-1-2011
Lj�WNER
NAME: `
ADDRESS:
PHONE:
. �OUR E-MAIL ADDRESS
���
❑CONTRACTOR
�I'�� iCa � c
�7 l � S4 !
STATE LICENSE # LEAD CERT NUMBER
ADDRESS:
[�SINGLE FAMILY/NEW CONSTRUCTION
0 TWO FAMILY/NEW CONSTRUCTION
� ADDITION ❑ GARAG
❑ BASEMENT FiNISH � ROOF
❑ DECK ❑ SIDING
❑ SWIMM
TYPE OF WORK: I ❑
DESCRIBE WORK BEING DONE:
S1ZE OF [MPROVEMENT
ROOFING
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
! SIDING
i ❑ Vinyl
O Aluminum
❑ Other
HOME CONSTRUCTION
WINDOWS
M EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
FAX
S[ZE
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
�-IOUSE & GARAGE
�ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
❑ WINDOWS
❑ DRAIN TILE
O OTHER
HEiGHT
Permit No.: � �' ��
Received By:,� "�— -
Date � � _���
A'
STATE ZIP,
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed Floor plan
3. List of sUuctural members to be used
FOR NEW CONSTRUCTCON MCLUD[NG DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WtNDOWS — PROVIDE U-VALUE AND
MANUFACTURE 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
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
ANCY TYPE
$ %j,/� d�j See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .� .001 times the total job valuation
$ l�_ .0005 x Permit Valuation Minimum $5.00
$ � v� $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 ( )
$ �, .(p � Make checks aavable to: Citv of Fridlev Attach
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 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 f 1 work which r rev ew and approval of pJ� �y'�� �`J���,�% 5�{� ll
SIGNATURE OF APPLTCANT�� ���%I�pRINT NAME /yl� ��''�—.G)��� f7 (^� /"" "pATE v ` �
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