P - 47307Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I1-2011
DATE�_�� 1�� l YOUR E-MAIL ADDRES
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THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
STATE LICENSE #
ADDRESS: �%/v
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PHONE Z�� % � 1�
❑ SINGLE FAMILYMEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH ��BOOF
❑ DECK ❑ SIDING
❑ SWIMM
SIZE
STORIES
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: V'--E� �` C='�" '' -�/�'--
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOU3E ONLY
NUMBER OF SQUARES �_..� �OUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
Permit No.:
Received By �
Date Rec'd:l�
��STATE�IP ,fjcJ �'y �
�
t EXP:
�`- STATE,�ZIP�[::�
- '-- �7�' � -��
❑ DRAIN TILE
❑ OTHER
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,
❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS & PORCHES SUBMIT
❑ Trim REMOVED? ❑ YES ❑ NO I. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STTCKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
/ (USING THE 199'7 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $[.//�, �v 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
� /�f, � 5 See Back Page for Fee Schedule
$ �-. 65% of Building Permit Fee
$ f_. !/ .001 times the total job valuation
$ �� n G .0005 x Permit Valuation Minimum $5.00
_ $ ..S : �� $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
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 des of the jty of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f a�rmit and o k is not to start without a permit on site; that the work wiil be in accordance with the
approved plan in the case of a hich - uir r iew and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME DATE r'� :�^j`J
APPROVAL INSPECTOR S IVA J