P - 47787Building
Inspections
763-572-3604
763-502-49,77 FAX
DATE (p � � 3 / r 1
SITE ADDRESS �
THIS APPLICANT [S
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
SIZE OF IMPRCIVFMFNT
ROOFING /
NUMBER OF SQUARES `�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
ADDRESS: �C y �`
C1.�C�Y'1
CITY
Permit No.: UU� �-W "�U v
Received By: .�,�
Date Rec' d: �Q �' ��J'" � �
�
ATE
STATE LICENSE # �� �`�'�– C � �� CERT NUMBE
ADDRESS: � �' ( C�.-t { -c CITY STAT Sd
PHONE —S�IP '
FAX
SfSINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES
❑ BASEMENT FINiSH
HED
❑ DECK ❑ SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODEI,ING
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ H011SE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF wlNn�ws
❑ WINDOWS
❑ DRA[N TILE
❑ OTHER
FT
BASEMENT REMODELING SUBMIT
1. 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.
.vt�i, r��;� A1ZE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TvpF
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �?,. L
$
$ %.{j
$
$ �j
$
$
$
$
$
$ �
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 payable to: Citv of Fridlev
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 d codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f a permit nd work ' not to start without a permit on si e• that the work will be i accor nce with the
approved plan in the case of a ork w ich e' iew and approval of pl /�
SIGNATURE OF APPLICANT PRINT NAME �C �P ��S�jl�I�DATE t! �` �
APPROVAL INSPECTOR SIGN F_. �� �/ �/ /%