P - 35436Building
Insp�ctions
76�-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS �
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:
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
I ING
❑ Vinyl
❑ Aluminum
� Other �'P�G f
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAtL ADDRESS
f�OWNER ❑CONTRACTOR
NAME:
STATE LICENSE
ADDRESS:
�SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
$�f ADDITION
O BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTTON
❑ MAINTENANCE/REPAIR
Permit No.:��
r `x'._
Received By: ' '�
DatL��'� �
ITY ��A I2 � STATE "�Z[P,Z
� /��� �9
EXP DATE
CITY STAT'E ZIP
FAX
SIZE
❑ GARAGE/SHED
❑ ROOF
�3 SIDING
❑ SWIMMING POOL
❑ ADDITION
'B�REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN T[LE
❑ OTHER
4 wq /'
HEIGHT
BASEMENT REMODELING SUBMI7'•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS & PORCHES SUBMIT
❑ Trim 1• Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two seu of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS T�Yes ONo LOCATION OF WiNDOWS FOR WINDOWS — PROViDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED e NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ S(g� � 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 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 (Pians to MWCC for determination)
$ ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable 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 wilt be in
confotmance 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 o�� hich requires review and approval of p s. / l L�- ( I
SIGNATURE OF APPLICANT PRINT NAME�[' �G�+� U'(�°eV� DATE
APPROVAL INSPECTOR SIGNANRE
A
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