P - 47258Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I � � I —�
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 11-2011
SITE ADDRESS �� � ` �j }�'
THIS APPLICANT 1S: ❑ OWNER
PROPERTY OWNER/ NAME:
TENANT �
ADDRESS: '�
PHONE: � o V �l
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
Permit No.:
Received By: l�+t� � �
Date��: '' �
YOUR E-MAiL ADDRESS _ � a�1��� „� � �� �,°��%>.7 ��� U 0V�. � .-� �
��. � c �„-,
STATE LICENSE #
ADDRESS:
PHONE
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH ❑ �i00F
❑ DECK �$IDING
❑ swrMM
NEW HOME CONSTRUCTTON
AT�_ZIP.
CERT NUMBER EXP:
CITY
FAX
SIZE
STORIES —
E/SHED ❑ WINDOWS
❑ DRAIN TILE
!NG POOL O OTHER
❑ ADDITION
❑ REMODELING
DESCRIBE WORK BEING DONE: 'S j d� hR-
SIZE OF IMPROVEMENT �� ,
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
ING
Vinyl
Aluminum
❑ Other
WINDOWS
IN EXISITNG OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit SIDING/SOFFIT/FASCIA
❑ Trim REMOVED? �YES ❑ NO
❑ Fascia
LOCATION OF WINDOWS
ATE ZIP
ncivn � SQ FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction pians
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW,
- ��i:nvr W1IVUVWJ
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $����USING THE 1997 U.B.0 FEE SCHEDULE)
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$ /.`� '�
$
$ �� �
$
$
$
ANCY
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
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED ~ a�■�i,�
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 m the case of a r h'
SIGNATURE OF APPLICANT r iew and approval , �(�
APPROVAL INSPECTOR SIGN�I4�E P�NT NAME_. il'r'�`i�i 1 i� DATE \�'��--- �- l t
�x�� .., ... ,�,, „