P - 48049Building
Inspections
763-572-3604
763-502-4977 FAX
DATE //l �' (� '"
SITE ADDRESS �
THIS APPLICANT [S:
PROPERTY OWNER/
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 IMPROVEMENT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201I
Permit No.
Received By:
' 'i
�. � . : � ,
YOUR E-MAIL ADDRESS � ✓ / %�.�IL � j,l�� �� }� /'y� r�/ (, . �i� �"�
�� � � ��
❑ OWNER �CONTRACTnR
ADDRESS: '.�7 ,�i ilF% • �� Fy?�i �
PHONE:
STATE LICENSE # � �7
ADDRESS: !/ f tlfa y
PHONE G✓ •� /� � � y —
�/� /���9 STATL�FJ ZIP S�i 3,�
LEAD CERT NUMBJER
� CITY( xlr-(� � / /�'1 �. STATE���IIZIPS�SL• �'f �
FAX /�l�`7'fi�
�SINGLE FAMILY/NEW CONSTRUCTION SIZE�
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ W[NDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMM[NG POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION �.
❑ MAINTENANCE/REPAIR ❑ REMODELING �(� � �%�,��,
ROOFING jjjyyy
NUMBER OF SQUARES � `T_ �
�!
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
_ L,r t:) � �—
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
i�I-IOUSE & GARAGE
❑ ATTACHED GARAGE
�GETACHED GARAGE
❑Soffit
❑ Trim .
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDO
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION RJCLUDING DECKS,
ADDITIONS_ & PORCHES SUBMIT
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 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
$
$
$
$ ,�
$ � �-��,
$
$
$
$
$
$ � 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 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: Citv of Fridlev
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 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 all work w' h requires review and approval of pl �j/ � �-
SIGNATURE OF APPLICANT � PRiNT NAME �/6� ��I �%�i� DATE ���--�%�
APPROVAL INSPECTOR SIGNATURE