P - 35172Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ��� � '�' /
SITE ADDRESS ��
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011 �
❑ OWNER
CONTRACTOR NAME: ✓��
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE #
AND CERTIFICATE OF ADDRESS:
INSURANCE pHONE �
AIL ADDRESS
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
C
Permit No.: �i ,i� � i�' � 3��
Received By:J`v t�' Q
� �
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A
ZI���7y'3�
CERT NLiMBER
CITY / STATE��/ZIP,;S .�1/
n,..�_ - — - --
FAX 7J � .3
SIZE
❑ ADDITION ❑ GA4ZAGElSHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION � ADDITION
$(MAINTENANCFJ�EPAIR ❑ REMODELING
ROOFING
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
O Other
WINDOWS
M EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRtBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
L�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
OF
F7'
BASEMENT REMODELING SUBMIT:
L Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION RJCLUDING DECKS,
ADD1T10NS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets 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:
(U5ING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ ,S'S�D 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
$
$
$
$
� -
See Back Page for Fee Schedule
65% of Building Permit Fae
.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 Fridley Attact
lations
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 an codes the Ci Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application r pe ' and w is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of e �ew and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME DATE
APPROVAL INSPECTOR SIGN RE