P - 46283Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � C��
SITE ADDRESS ...5��'/
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
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❑ OWNER
NAME:
ADDRESS: �_��/
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YOUR E-MAIL ADDRESS
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❑CONTRACTOR
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CITY
Permit No.:,�.�}�� ° (1U`' '
Received By: � �
Date Rec'd: r�.- �.�% � �
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STATE LICENSE #� t�S�� ��/4/k' . LEAD CERT NUMBEIj,�%�/��Si�G �-O!J/%,;,5'
ADDRESS:_Sy� � �{yL� f;l �,��� CITY �/�� STAT �ZIP f.f��7d°
PHONE �I ��t/ �— So���. FAX %6 3— i 1a- �&�'7$.
.BtSINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
- TYPE OF WORK: I❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING
OF
ROOFING �
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
� Other
WINDOW S
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
SIZE
STORIES
❑ GARAGE/SHED
r�ROOF
❑ SIDING
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
�}}-IOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
� Trim
❑ Fascia
LOCATION OF WINDOWS
OF
❑ DRAIN TiLE
❑ OTHER
dl z�'
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of svuctural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS_ & PORCHES SUBMIT:
I. 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:
(USING THE 1997 U.B.0 FEE SCHEDULE) .
TOTAL JOB VALUATION $ 9. 7pD, t�� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$ �/, ��_ See $ack 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 Residentiat 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
Attach
THIS IS AN APPL�ICATION 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
conformartce 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 st�-t without a permit on site; that the work will be in accordance with the
approved plan in the case of atl work which requires review and approval of plans.
SIGNATURE OF APPLICANT PRMT NAME DATE
APPROVAL INSPECTOR SIGNATURE
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