P - 35775Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �
SITE ADDRESS
�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
L ADDRESS
❑ OWNER I�ONTRACTOR
NAME: W � ( � L U (M � ��/V�%
ADDRESS: CITY
STATE LICENSE # � LEAD ERT NUMBER,
ADDRESS:� ��J ,� �
/ � , �� . �,����v�,
PHONE F,q}{
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTiON STORIE �
PERMIT TYPE � /�DITION
❑ BASEMENT FINISH
O DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTlON
�1GiAINTENANCE/REPAIR
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED NE[GHT:
IS DING
❑ Vinyl
❑ Aluminum
❑ Other
❑ GARAGE/SHED ❑ WINDOWS
❑ ROOF ❑ DRAIN TILE
❑ SIDING �"6THER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
O HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
HEIGHT
' - • ,�,..�' 1'�l�'�ii
i� a� � , � f� .
� . _ . � � .� Y I� •
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ATE ZIP
STA
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION [NCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Pian/Survey showing ihe existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$ s
$ .SDO
See Back Page for Fee Schedule
65% of Building Pertnit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC nit (Plans to MWCC for determinai )
� ft+��-- ZO ft x$25= $ SOO
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: Citv of Fridlev Attach
lations
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a building permit and I acknovuledge 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 of all work which requires review an proval of plans. �
SIGNATURE OF.APPLICANT A PRiNT NAME DATE
APPROVAL INSPECTOR SIGNATURE .s,Ael