P - 37230Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_ �I � � I °� G � �
SITE ADD� S o�g (7
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BESCRIBE WORK BE3NG
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
BUILDING
RESIDENTIAL APPLICATION
/tSOWNER
.ME: � 1/�
iDRESS: SF
NAME:
STATE LICENSE #
ADDRESS:
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MA1L ADDRESS r�
❑CONTRACTOR
,�--
. � Gl
Permit No.:
Received By: ���(,�
D��c'� ..
4,
STATtYVi w ZIP
CERT NLJMBER
_ CITY STATE ZIP
PHONE FAX
❑ SINGLE FAMILYINEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�1GIAINTENANCEIREPAIR ❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
SIDING �—'�
❑ Vinyl �pSoffit
�❑ A minum �rim
er C%� �cia
WINDOWS
IN EXISTING OPENINGS Yes �No LOCATION OF WI
OR FOR NEW OPENINGS-DESCRIBE SIZE OF �
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor pian
3. List of struc!ural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT:
l. 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.
OPENING CHANGES & �
TYPE OF WINDOW TO BE INSTALLED C-a�' �> >°^'� NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
SING THE 199 FEE SCHEDULE)
TOTAL JOB VALUATION $ � �--�CJ � OCCUPANCY TYPE
Permit Fee $ `j See Back Page for Fee Schedule
Ptan Review $ - 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $223Q per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Bngineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ Q'1- Make checks aavable to: Citv of Fridley Attach Stipulations
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 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 woi c which requires review and approval of p1�p� �_s C �
SIGNATURE OF APPLICANT �---- PRINT NAME �.D v� S��-i DATE p � ti� ,
APPROVAL INSPECTOR SIGI�ATUR