P - 48276�uilding
Inspections
763-572-3604
763-502-4977 FAX
DATE ' Z 2'
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/ I NAME�
TENANT ADDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTffICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING D(
SIZE OF IMPROVEMENT
NU�MBER OF SQUARES _
GARAGf�
PROPOSED SIZE:
PROPOSED HEIGHT:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1 ]-2011
YOUR E-MAIL ADDRESS
�" �� �-
❑CONTRACTOR
CITY j�U � [ C{ (1
� - I . J ' .5^��0
���G�-
Permit No.:
Received By: 1 J fl I"
Da�'d� f � �
A.�,� U -, „�p.
_L�y�
STATE LICENSE # LEAD CERT NUMBER EXP:
ADDRESS: CITY STATE ZIP
PHONE FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
SIZE
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCF/REPAIR ❑ REMODELING
LENGTH WIDTH
�IOUSE ONLY
_ ❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN TILE
❑ OTHER
BASEMENT REM E
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl � ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMI7':
O Aluminum �'�_ ❑ Trim REMOVED? ❑ YES O NO �• Site Plan/Survey showing the existing structuros
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
�'�' 3. Energy Calculations
EXISTING OPENINGS es ❑No LOCATION OF WINDOWSp FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENRIGS- ESCRIBE SIZE OF 'rJ S F� � �� /� � 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 E 1997_U.B.0 F�CHEDULE)
TOTAL JOB VALUATION $ � _ , � g-p �� _ _ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Suroharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
W
$
$
$
$
$
$
$
$ �
See �ck Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.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 necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTTL 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 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 r hich r uires review and approval of pl
SIGNANRE OF APPLICANT � � � PRINT NAME �(���'j�DATE ! q « �2 — � ,
APPROVAL INSPECTOR SIGNA u .�—
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REVIEWED FOR
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