P - 41838Building
Inspections `
763-572-3604
763,-502-4977 FAX
DATE / �
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OP
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE i-I-2011
YOUR E-MAIL ADDRESS
c�.� i�� vU IC
r�
_CITY_
�
NAME:
STATE GICENSE # LEAD CERT NUMBER
�E FAMILY/NEW CONSTRUCTION
FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISN
❑ DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTIQN
� MAINTENANCE/REPAIR
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HE(GHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other 'rCv� �
FAX
SIZE
STORIES
❑ ROOF
❑ SIDiNG
O SW1MMfNG POOL
❑ ADDITION
❑ REMODELtNG
� HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS es ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS- ESCRI�E SIZE OF
OPENIIJG CHANGES & �u„ �, / � M1i„� / �
�
CTTY
Permit No.: U 1 i'� 1 i(•'�
Received By: `'t� �
Date �c,'�c : � � P � � �
� �'�i'L-/'�.C�l�/
-�o �
STATE �ZiP S�Y.�Z
ATE ZIP;
D DRAIN TILE
�OTHER � � �'���o►-tin...
F7'
, r 1,
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION ►NCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing sVUCtures
and proposed projoct.
2. Two sets of construction plans
3. Energy Calculations
FOR WMDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WMDOW TO BE IN TALLED NUMBER OF WINDOWS —7 �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
j� (LT�SING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB `JALUATION'
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$
$
$
$
'ANCY TYPE
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 Stipulations
THIS IS AN APPLICATION FOR A PERMiT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acloiowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances codes f the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a rm' and work is not to start without a permit on site; thaf�the work will be in accordance with the
approved plan in the case of w c w' ' e review and approval of p c !`-^
SIGNATURE OF APPLICANT . PRINT NAME �)I � S��GM�( DATE � "`CD ^ � �I _
APPROVAL INSPECTOR SIGNA RE .
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