P - 42767Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 7
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
_ EFFECTIVE 1-1-2011
YOUR E-MA[L ADDRESS
SITE ADDRESS � "
THIS APPLICANT IS: �F�WNER ❑CONTRACTOR
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 IMPROVEMENT
ROOFING ,�
NUMBER OF SQUARES; � �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
� Vinyl
❑ Aluminum
❑ Other
NatvtE: rSc��f^IN� G"�'� �' 1� ZJ °7�'..�^s
.aDDRESS: (o �z`Z� "� "�" Sr� rY �
PHONE:_TIv.� , .S„" �� I� c� .,5�-��
NAME:
STATE LICENSE #
ADDRESS:
PHONE
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
O BASEMENT FINISH
❑ DECK
❑ GARAGE/SHED
�'ROOF
❑ SIDING
❑ SWIMMING POOL
Permit
� - - � : .�...�r
.
�� !-�. .�
-' � �
L° l% �;,.p�lS . v .., a�
CITY��� STATE i� ZIP 5����
LEAD CERT NUMBER
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAM TILE
❑ OTHER
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODEL(NG
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE STZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
TH
0 HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
C]Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
OF
HEIGHT
STATE ZIP
FT
BASEMENT R MODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT•
]. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
`,� SING THE 1997 U.B.0 FEE SCHEDULE)
COTAL 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
$
$ •
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuati4n Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks payable to: Citv of Fridlev
Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[[, 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 witl be in accordance with the
approved plan in the case o�all rk whi�h re uires review and approval of pl , s.
SIGNATURE OF APPLICANT ��� � y�� �yy PRINT NAME�' q�'�'{� '� �() i��",S DATE ��/��j/
APPROVAL INSPECTOR SIGNATURE _ � �—