P - 45303Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
S[TE ADDR SS _
TH[S APPLICANT [S
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E—MAIL ADDRESS
`� OWNER ❑CONTRACTOR
Permit No.: :=�(; � � � � 1 ��� �
Received By: ,�'�?�Gl�
Date Rec'd: � ' � � "� � �
NAME: A�a✓/ i� C—' �" ! CG? �%�
ADDRES�-1-.J �t� ,%7—i.E' �� CITY ��/IC�/''Ir STATE%y� ZiP S��
,
PHONE: ��G� ' .� *� `— 2��T_
NAME:
STATE LICENSE # LEAD CERT NLIMBER
ADDRESS: CITY STATE ZIP
PHONE FAX
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINi�OWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
fE: � �t3 �� ' ��" � '
LENGTH WiDTH HEIGHT
ROOFING � �
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum ' �'1
�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
❑So�t
❑ Trim
O Fascia
LOCATION OF WINDOWS
NUMBER OF WML
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu 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:
�,�,.��SI_N�G TH� 1 97 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ ( i����j 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
$
$
$
$
$
$
$
� Z.
See Back Page for Fee Schedule
65% of Building Pertnit Fee
.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$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks aavable to: Citv of Fridlev
Attach Stipulations
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby apply for a building permit and t 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 of al �,�,� whi requires eview and approval of p,�i nsL� ���� _/
SIGNATURE OF APPLICANT �'r����� PRINT NAME/!(K- �C6�_DATE /�
APPROVAL INSPECTOR SIGNATURE