P - 37427Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 22 ��I
SITE ADDRESS v �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
ii TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF fMPROVEMENT
ROOFING z
NUMBER flF SQUARES 2-/
i GARAGES
i� PROPOSED SIZE:
! PROPOSED HE[GHT:
BUILDING
RESIDENTIAL APPLICATION
�OWNER
NAME:_
ADDRESS:
CITY OF FRIDLEY
EFFECTIVE 1-1-20] 1
YOUR E-MAIL ADDRESS _
/�� �"s'� tt�%3 fr , ,
❑CONTRACTOR
� SGQ��'�
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rs / n .- /.2G' �
NAME:
STATE LICENSE #
ADDRESS:
PHONE
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ,�ROOF
❑ DECK ❑ SIDING
❑ SWIMMING PO(
Permit No.:
Received By:
� . .,�,M �;► � � , � I
/� � �j��'� ��/%� CL��' G�
CERT NUMBE
CITY
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
Q NEW HOME CONSTRUCTION ❑ ADDITfON
❑ MAINTENANCE/REPAIR ❑ REMODEL[NG
_ t) n ril/1 T., C-f`iY'1rii1
❑ HOUSE ONLY
�IOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
ATE
�ZIP � �
ATE ZIP
FT
BASEMENT REMODELMG SUBMIT:
t. Existing Fioor Ptan
2. Proposed floor plan
3. List of structural members to be used
� SIDING FOR NEW CONSTRUCT[ON INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ fiascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
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
$ �l' �/- LS
$
$ �
$
$
$
$
$
$
$
$ 1� , .��
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 payable to: City of Fridley
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 ity of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and rk is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all work h re ' es eview and approval of plans✓ �,�� `
SIGNATURE OF APPLICANT PRINT NAME /�i���� DATE Gif/
APPROVAL INSPECTOR SIGNATUR