P - 47400Building
Inspections
763-572-3604
763-502-4977 FAX
DATE lY � �'�
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
SIZE OF
BUILDING
RESIDENTIAL APPLICATION
Permit No.:
Received By:
CITY OF FRIDLEY I Date��e�'a:
EFFECTIVE 1 1 20ll
YOUR E-MAIL ADDRESS TL�CC/" T-S �!✓���a'' � ��`
❑ OWNER �CSNTRACTOR
NAME:
ADDRESS:�
PHONE: �7Z.
NAME: T l.� �. (./� rwvr � s
STATE LICENSE # � � Y-fY� �4 �
ADDRESS: ��� YOrf� f�1/'Q
R�SINGLE FAMILY/NEW CONSTRUCTION
O TWO FAMILYMEW CONSTRUCTtON
n n nnrrint� ❑ A(
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
ROOFING �G�
NUMBER OF SQUARES [
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
^" WINDOW TO BE INSTALLED
T ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(U G THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�• �"� OCCUPANCY TYPE
❑ SIDING
❑ SWIMM[NG POOL
❑ ADDIT.
❑ SE ONLY
HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
CITY
ATE/�VI/�ZIP
CERT NUMBER
CITY �/%�e✓�� STAT&s�?�e'ZIP S_��+�'
FAX
SLZE
STORIES
❑ DRAIN TILE
❑ OTHER
HEIGHT
FT �°��
BASEMENT REMODELING SUBMIT:
L Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & 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.
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
%�
..1�'�
��,
See Back 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 pavable to• City of Fridley Attach
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 only an application for a permit d w i o art without a permit on site; that the work will be in accordance with the
approved plan in the case of all e' e and PRI�NT NAMEp]an�/'��� ����� �` DATE `O `l� ��
SIGNATURE OF APPLICANT
APPROVALINSPECTORSIGNATUR �_-___�_ _�.�.-.�:..<..x�Y.,,n�� ,-,r r.r�Tna�,nr .nT:rnxA�'.�'WATT�f'�?;�741('1R� ' �.'