P - 48017Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_�_
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A CQPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMTT TYPE
TYPE OF WORK:
DESCffiBE WORK BEING
SIZE OF IMPROVEMENT
ROOFIN
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
❑ Aluminum
❑ Other
BUILDIN�
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 11-2011
❑ OWNER
PHONE:
YOUR E-MAIL ADDRESS
'- �i���J
NAME: rtTl 1 J'� j� � l c�� l� r"Y \.l �:�[ 1 �
STATE LICENSE # LEAD
ADDRESS: 1.�`�_IGI- _ � I`.�l.J����.-��-.. �
YHUN� � f/� J ( - �t�l�C'i -- T `7
�6,jNGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCI'ION
❑ ADDITION O GARAG
❑ BASEMENT FINISH ❑ OOF
❑ DECK �SIDING
O SWIMM
O NEW HOME CONSTRUCTION
❑ MAINTENANCFJREPAIR
Permit No.:����
Received By:� I �
���� � � � Z���
FAX (C�J I - ��.-� '-
S1ZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
t'P_ M v..:� C� ,� � 1 ci.t.�... J i
�LENGTH WIDT
�� ONLY
Lj ) �_ ` 0�3��RAGE � � �
U�ATTACHED GARAGE� j 1
� . �C�U- ❑ DETACHED GA
,.-�---- vi` 1 � ��
� i ��.� ` —
Soffit SIDING/SOFFIT/FASCIA
❑ Tri EMO 7 ❑ YES
Fascia (� �I
�I .N��
l Y"1 �Yl �.%5J1.. "� L C�C'�
�
HEIGHT SO 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:
O NO 1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
I WINDOWS 3. Energy Calculations
IN EXISTTNG OPENINGS ❑Yes �No LOCATION O�VINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENIlVGS-DESCRIBE SIZE OF MANUFACTCJRE STICKER ON WINI�OW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NiJMBER 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
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erdsion Control
Park Fee
Sewer Main Charge
Total Due
$ I �.�7.5
$
$
$ �� �- —
$
$
$
$
$
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 (
to: Citv of Fridlev 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 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 of a11 which requires review and a val of plans.
siGrra� oF .�rLicArrT �.���� �.�s�. is-�.� !�._ �., �I�-..,�vA� i Z Ia Z. � U
APPROVAL INSPECTOR SIGNA
PLEASE NOTE: SEPARA PERMITS ARE REQUIRED FQR PLUMBING, EI,ECTRICAL AND MECHANICAL W�RK