P - 39623Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/ I N
TENANT �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20ll
YOUR E-MAIL
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�IOWNER ❑CONTRACTOR
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�RES �
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Permit No.:
Received By: ���t�
Date I�� � � � ' .� � �
A
NAME:
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: CITY STATE ZIP
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
FAX
SIZE
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
��AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �J
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING �[-IOUSE ONLY
NUMBER OF SQUARES�__ �jQUSE & GARAGE
GARAGES
PROPOSED S[ZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
� WINDOWS
❑ DRAIN TILE
❑ OTHER
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDITiG DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No 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 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 $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ h'� •1�,�
$
$ �.
$ 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 pavable 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 will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Conshuction Codes; that I understand this is not a
permit but only an applicatio for a pe • it and work is not to start without a p it on site; that t wo w�ll be in accordance with the
approved plan in the case of •e u r d approval of plan . /����`— � 1�' ����-2-�L�
SIGNATURE OF APPLICANT � PRINT NAME '� DA'I'E
APPROVAL INSPECTOR SIGNATURE