P - 47295Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /( —���
SITE ADDRESS ��
THIS APPLICANT IS:
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 TMPR(1vF�.,rcT.r�r
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
❑ Other
BUILDING Per,.,,;t No.:'�a �.(p
RESIDENTIAL APPLICATION Received By:
CITY OF FRIDLEY Dat��dN � U' � O
EFFECTIVE 11-2011
YOUR E-MAIL ADDRESS � i
� i1 �
�
❑ OWNER �C(1NTRn��rno
NAME:
ADDRESS:
PHONE:
NAME: ( .�� �..._ iL.d % _ _ .1 1
CITY
ATE ZIP
STATE LICENSE � ���5; LEAD RT NUMBER `
ADDRESS:1��135/ (`i,,,, ,Q�� EXP:
PHONE � , .� � ���__�y'_-----CITY F•, •. STATE,��IP f7,3]
— 9.� � ��� S� � S� FAX �.S �Z S/�t1 /.1� 7
❑ SINGLE FAMILY/[YEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION
,� ..,,.,,T.�.. STORIES
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
O MAINTENANCE/REpAIR
WINDOWS
IN EXISTING OPENINGg es ❑No
OR FOR NEW OPENING -DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED ��
ALL FEES ARE BASED ON V
TOTAL JOB VALUATION $
Permit Fee
Pian Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
❑ GARAGE/;
❑ ROOF
❑ SIDING
❑ SWIMMIN
❑
❑ HOUSE ONLY
O HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN TILE
❑ OTHER
.:.vn i 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,
❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS & PORCHES SUBMIT:
❑ Trim REMOVED? ❑ YES ❑ NO �• Site Pian/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
LOCATION OF WINDOWS 3 Energy Calcu(ations
FOR WINDOWS — PROV[DE U-VALUE AND
MANUFACTURE STICKER ON WINDpW.
NUMBER OF WINDOWS
LUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�ING THE 1997 U.B.0 FEE SCHEDULE)
OCCUPANCY �rvn�
�% �� See Back Page for Fee Schedule
65% of Building Permit Fee
$ �.001 times the total job valuation
$ � �C� .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 necessa
ry ( ) Non Necessary ( )
$ ��Li 5 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 codes of the C' of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applica ' n fo a permit d k is ot to start without ermit on site; � the work will be in accordance with the
approved plan in the case f rk whic re res rev' nd approval of s.
SIGNATURE OF APPLICAN �
APPROVAL INSPECTOR STGNANRE P�NT NAME V�/ DATE //—' — l�
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