P - 45305Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �-�
SITE ADDRESS 7
THIS APPLICANT IS:
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
ROOFING /
NUMBER OF SQUARES L i
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyi
❑ Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT]VE 1-I-2011
YOUR E-MAIL ADDRESS
❑ OWNER
rta,NtE: _{ � n ; � ��i � � ;�
ADDRESS:
PHONE:
NAME: ( �t"<#
STATE LICENSE #_
AbDRESS: �t/ S
�.�
�,
Permit No.:
. �
Received By:
Da�c� d,,;) U %., .� � � � �
STATE ZIP,
LEAD CERT NtIMBER
CITY /7� s-.., {(.� STATE�✓ZIP �J S 30 c/
PHONE /(, ,) �- �4��C_/ FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING O OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR tJ REMODELfNG
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WTNDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
WTDTH
BASEMENT REMODELING SUBM)T:
I . Existing F)oor Plan
2, Proposed floor plan
3. List of structural members to be used
FOR NEW CONS7'RUCTION INCI.UDING DECKS,
ADDITIONS & PORCHES SUBM]T�
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 LA$OR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
fOTAL JOB VALUATION $ 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
$ � C�`��-- - - -
$ �
$ /-'��
$
$
$
$
$
$
$
$ (i
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 lJnit (Plans 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 Fridley 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 compiete 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 fo�r �r it and work is not to start without a permit on site; that the work wi11 be in accordance with the
approved plan in the case of al r6o l ich re ' es review and approval of plans.�'/ �� � ^7 �?
SIGNATURE OF APPLICANT PRiNT NAME ��7'`l � DATE / � l J' rI
APPROVAL 1NSPECTOR SI A RE