P - 47257Building
Inspections
763-572-3604
763-502-4977 FAX
'� DATE • � / '
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 W ORK:
SCRIBE WORK BEING
ir� -� � �
BUILDING
RESIDENTIAL APPLICATION
❑ OWNER
CITY OF FRIDLEY
EFFECTIVE 1-1-201]
_ OUR E-MAIL ADDRESS
�ONTRACTOR �
ADDRESS: /L%�� [p�aZ�'� (�
PHONE:
NAME: — (�
STATE LICENSE # D �—I
ADDRESS:�
PHONE — � —� �j L�
�'�INGLE FAMILY N
❑ '�'VO FR�fILY1N�W CONSTRL'CT;ON
❑ ADDITION ❑ G�ARAG
❑ BASEMENT FINISH ,0'i�pOF
❑ DECK ❑ SIDING
❑ SWIMM
�
S1ZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES � �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
HOME CONSTRUCTION ❑ ADDITION
fTENANCE/REpAIR ❑ MODEL'
i -- C
L WIL
❑� �H USE ONLY
-I�HOUSE & GARAGE
.�'ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINnnW Tn uF n.te�rn7 r c�.� ___
CITY
CERT
FAX �P SI — ,I
SIZE
STORIES
❑ DRAIN TILE
❑ OTHER
Permit No.:
' - - � � ��,i�ttrl
l
� ,. _ • > , � ,•; ► �
1 � il - " "`
STATF�JYJ N ZIpJ
�
^ �� ATFY� ZIP
�
FT
BASEMENT REMODELING UBMIT�
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHE UBMIT
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 11�IATERIAI,S;
�YG T�E 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ a 7• OCCUPANCY
Permit Fee TY�'E
Pian 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
$ �,� �i' � .001 times the total 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$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ � Agreement necessary ( ) Non Necessary ( )
$ � MBke cherka nAV�hlo t... �a... ,.e �
--���� 1� r✓ a.uJ Vi r�'fdley 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 Ci of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applica ' n for a permit and o k is not to start without a permit on site; at the work will be in accordance with the
approved plan in the case ork whi requ' e ev' w an approval of plan .
SIGNATURE OF APPLICANT PRINT NAME � LL.� i'Y� f f�1, � J
APPROVAL INSPECTOR SIGN DATE �
.. . �Di L` A ct'r',•. urr.m'r ..�.-....'. � . =_....� . ... ............ .. ...