P - 39366Building
Inspections
763-572-3604
763-502-4977 FAX
DATE / �—
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWIVER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201I
UR E-MA1L ADDRESS
i<"-z�-lz� �'.�: �
OWNER ❑CONTRACTOR
�� � �S� � �
ADDRESS:
STATE LICENSE #
PHONE
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PermitNo.��?���� ����
Received By:
Date R���: � � � � �
°'}""�,�'✓��,�/�/ '� ✓ �
�=�l�Y LL\ � � STA
�
LEAD CERT NUMBER
CiTY
FAX
SIZE
STORIES
❑ BASEMENT FINISH /�'ItOOF ❑ DRAIN TILE
❑ DECK •SfSIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE:
ROOFING , j7 1Q/"�� �) ❑ HOUSE ONLY
NUMBER OF SQUARES "i t) �'�� �'' �l ❑ HOUSE & GARAGE
.�-- ..
GARAGES � � ❑ ATTACHED GARAGE
PROPOSED SIZE: e�`� ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
'❑ Vinyl �. /� � l'y� "' �offit
❑ Aluminum �� n n � � ❑ Trim
(�ther , Y� 1/1, ❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
LOCATION OF WINDOWS
NUMBER OF
WIDTH HEIGHT
S ��/
ATE ZIP
FT
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDTNG DECKS,
� ADDITIONS. Bc 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:
�^ (USJ.P�G THE 1997 .B.0 FEE SCHEDULE)
COTAL JOB YALUATION $�,�S� ��a,y� 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
$
$ �
$
$
$
$
$
$
$ �a• I 3
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: 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 Construction Codes; that I understand this is not a
permit but only an application for ' not to start without a permit on site; that the work will be in accordance with the
approved p(an in the case of' '-revie�a-and approval of pia
SIGNATURE OF APPLICANT v PRINT NAME �,��e�GY /ti����� %� ^ 7'I �
APPROVAL TNSPECTOR SIGNATURE