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Building
Inspections
763-572-3604
763-502-4977 FAX
DATE Y r
SITE ADDRESS
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
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❑ OWNER
PROPERTY OWNER/ I NAME:,
TENANT � ___
CONTRACTOR
SUBM[T A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
t
STATE
YOUR E-MAIL ADDRESS
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�ONTRACTOR
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SII�{GLE FAMILYMEW CONSTRUCTION S]
TWO FAMILY/NEW CONSTRUCTION S�
❑ ADDITION GARAGE/SHED
❑ BASEMEIVT FINISH �ROOF
❑ DECK � SIDING
Cl SWIMMING POOL
❑ NEW HOME CONSTRUCT1013 ❑ ADDITION
�MAINTENANCE/REPAIR O REMODELING
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CERT N
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❑ DRAIN TILE
❑ OTHER
Permit No.� f ���� J
Received By: .
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ROOFING Q ❑ HOUSE ONLY
NUMBER OF SQUARES � ❑ HOUSE & GARAGE �ASEMENT REMODELING SUBMTT:
i. Existing Floor Plan
GARAGES � ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of swctural members to be used
PROPOSED HEIGHT:
IDING FOR NEW CONSTRUCTION INCLUDING DECKS,
AADITIONS. 8r, PORCHES SUBMIT:
❑ Viny! ❑So�t 1. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim
❑ Other ❑ Fascia and proposed project.
2. Two sets of conatruction plans
WINDOWS 3. Energy Calculallons
IN EXISTING OPENINGS OYes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U•VALUE AND
OR FOR NEW OPENINGS-DESCRIBE StZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BA5ED ON VALUATION, INCLUD[NG THE COST OF LABOR AND MATERIALS:
S[N THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUAT[ON $ OCCUPANCY TYPE
Permit Fee $ 1 ,� See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Suroharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Pians to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x�25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ 1 ,` Make checks uavabie to: Citv of Fridiev Attach Stioulations
THiS (S AN APPUCATION 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 t o 1 w ieh r uire evie d approval of pl � V
SIGNATURE OF APPLICANT PRINT NAME �����P/� l�-b �( DATE $G � � 14 (
APPROVAL 1NSPECTOR SIGNATURE
PLEASE NOTE: SEPARATE ITS ARE REpUIRED FOR PLUMBING, ELECTRICAL AND MECHANIGAL WORK