P - 35820Building
Inspections
763-572-3604
763-502-4977, FAX
DATE D % J /
--�
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
❑ OWNER �GNTRACTOR
NAME:
CITY
Permit No.:
Received By: . '�y � ' '
Date R� �
ATE N _ZIP
PHONE: (� /���� •��
CONTRACTOR NAME: O/ �,e
SUBMIT A COPY OF STATE LICENSE # 2� � LEAD CERT NUM
YOUR STATE LICENSE � � �� - � �
Al*ID CERTIFICATE OF ADDRESS: �D% �Y � I CITY O S!�li�d STATEi'MK�ZIP��
INSURANCE pH NE • Z. FAX G.
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION �ARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ROOF ❑ DRAIN TILE
O DECK ❑ SIDING O OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑�iEW HOME CONSTRUCTION ❑ ADDITION
L�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: •
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES Z1_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
' SIDING
' � Vinyl
❑ Aluminum
❑ Other
WINDOWS
TN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF_WINDOW TO BE INSTALLED
�..
❑ y6iJSE ONLY
QrHOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
�l1ll��l,l
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTtON tNCLUD[NG 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 $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Iviain Charge
Total Due
$ �r3rd5
$
$ _
$
$
$
$
$
$
$
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 aavable to: Citv of Fridlev
Attach Stipulations
1'HIS [S AN APPLICAT{ON FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a buildin permit and I acknowled at the information above is complete and accurate; that the work will be in
conformance with the ordina es an c d of ' o ridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicat' f not to start without a permit on site; that the work will be in accordance with the
approved plan in the case r vie and approval of
S[GNATURE OF APPLICANT PRINT NAME ��a �� ��'�� DATE S J�
APPROVAL INSPECTOR SIGNATURE