P - 47810Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�-�1 �Q
S[TE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNEW
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPR(�VFnnFt�T
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
' EFFECTIVE 1-1 2011
�--_—r��YOUR E-MAIL ADDRESS
6 �C -�
❑ OWNER CONTRACTOR
NAME: ) J� �
ADDRESS:
CITY
PHONE:
NAME: C�� C y� �';G,
�.,� ,
STATE LICENSE # LEA�
ADDRESS:
PHONE
Permit No.:
._
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.. � �- F •�
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ATE ZIP
_ �-/�UJ CP �
CERT NUMBER
CITY.}�� ���c� STATE � IP
FAX
SINGLE FAMILY/NEW CONSTRUCTION S[ZE
TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
. � � b' Yb i� 0f , C' : d-.n n ,. , _ ..y
❑ HOUSE ONLY
�I HOUSE & GARAGE
�ATTACHED GARAGE
DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
� �n�un � SQ FT
BASEMENT REMODELING SUBMIT
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT:
�. Site Plan/Survey showing the existing structures
and proposed project.
I WINDOWS 2. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WiNDOWS 3� Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROVIDE U-VALUE AND
OPENING CHANGE3 & MANUFACTURE STICKER ON WINDOW.
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 TYPF
Permit Fee
Plan 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 Pennit 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+6 ft= ftx$25=$
� $450 Conservation Plan Review
$ Fee Determined by Engineering
� Agreement necessary ( ) Non Necessary ( )
� � j' Make checks pa able to City of Fridle Attach
THIS IS AN AppLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED r
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 ork ' h ires review and approval of pla
SIGNATURE OF APPLICANT �p , , � ���� � j^ /^' _���
PR1NT NAME �/ WZ.- � �
APPROVAL INSPECTOR SIGNATURE DATE
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