P - 37422Building
Inspections
763-572-3604
763-502-4977 FAX
DATE a'a� "'��,
SITE ADDRESS
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATB LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
BUILDING
RESIDENTIAL APPLICATION
❑ OWNER
ADDRESS
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MAIL ADDRESS
� i
❑CONTRACTOR
� A- ~
--�� % A.1/'-P � CITY .
PHONE: 7(� �^ ,�` 7 %'— � �T_
NAME:
STATE LICENSE # LEAD CERT NUM
ADDRESS: CITY
PHONE
FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �J200F ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
� NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
ROOFING
NUMBER OF SQUARES ��_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
IDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
LENGTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
HEIGHT
Permit No.:
Received By: � V i��_
D������ � � ���1
STATE�^�ZIP,��
ATE ZIP
FT
BASEMENT REMODELTNG SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of struckural members to be used
FOR NEW CONSTRUCT[ON INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. 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 MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL 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
$ ���,�.�
$
$
$
$ (}
$
$
$
$
$ H
$ �,�.�.��
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 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
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 of al work which r rev�e and approval of plans. {�� /
SIGNATURE OF APPLICANT ���,���d„�f �� PRINT NAME �D�A ��% �O'� A,Q�/�� � DATE_ 1� o� �' � I
APPROVAL INSPECTOR SIGNATURE