P - 39653Building
Inspections
763-572-3604
763-502-4977 FAX
DATE-- lf/�`%/
—�T
SITE ADDRESS �;
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROP�RTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING /
NUMBER OF SQUARES a� cU
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
0 Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE I-1-09
YOUR E-MAIL ADDRESS
❑ OWNER ,�CONTRACTOR
CITY
r� 1
Permit No.:
�
Received By;�
Date Rec'd�.
ATE
STATE LICENSE # o EXP DATE �3/�///��
ADD�SS:�PDD G�` U� �(/� CITY�//��O STA
PHONE 7iP 3 � � �/ � �� �D FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONS'1RUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIIZ ❑ REMODELING
❑ HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
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 ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site PlanlSurvey 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
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USIN THE 7 U.B.0 FEE SCHEDULE)
TOTAL JOS VALUATION $ OCCUPANCY TYPE
Permit Fee $ ,2. See Back Page for Fee Schedule
Plan Review $ --►_.. 65% of Building Permit Fee
Fire Surcharge $ �� / .001 times the total job valuation
Surcharge $ j�- / .0005 x Permit Valuation Minimum $.50
License Surcharge r pv $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2000 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft = ft x$21 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ O. Make checks payable to: City of Fridley Attach Stipulations
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 City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but oniy 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 re ires review and approval of plans. Se� �
SIGNATUREOFAPPLICAN PRINTNAME �%�Q-�il� �C��DATE �oZ �
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK