P - 36777Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /f05 %
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPF,RTY TXPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-09
YOUR E-MAIL
❑ OWNER f�ONTRACTOR
NAME:
CITY
. � � � � � � � �
Permit No.:
Received By:
..:��:,�,
ST
STATE LICENSE # EXP DATE ��%���
ADDRESS: �Di�O �l�t"�%"�SD� �.�� CITY �Svc�(� ST
PHONE /(D �J — � `i/ — J' � /U
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH �IROOF
❑ DECK �SIDING
SIZE --.-----
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDTTION
�(MAINTENANCE/REPAIIi ❑ REMODELING
DESCRIBE WORK BEING DONE: �/:.�/%7Q ¢ I�DD �/%�
—�
SIZE OF IMPROVEMENT LENGTH WIDTH
NUMBER OF SQUARES �Y%,7 l��� ❑ HOUSE &NGARAGE
GARAGES
PROPOSED S1ZE:
PROPOSED HEIGHT:
SIDING
Vinyl • j 3 �
� Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGH'I'
FT
BASEMENT REMODELING SUBMTT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit �DTTIONS. & PORCHES SUBMTT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculahons
IN EXISTING OPENINGS �Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENII�IGS-DESCRIBE SIZE OF
OPENING CHANGES &
TXPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
'OTAL JOB VALUATION $��i F THE�1�,7�U�B.0 FEE SCHOCCUPANCY TYPE
`'�
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �7,a s
$
`✓ y /
$ 1 ---
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$2000 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$21=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks navable 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 o 1 work which • quires review and approval of plans.
SIGNATURE OF APPLICAN PRINT NAME �r6�r� Bess��t DATE �
PLEASE NOTE: SEPARATE PERMITS ARE REOUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL