P - 37481Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ^ �� ' �I
S[TE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS �� �/%CC�. �%
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❑ OWNER ❑CONTRACTOR
NAME: J `u �L:
ADDRESS: �S�L' I C�..l��%,�i� I�-� C►TY �%Q�-�'J
PHONE: �% " Z�P � ' LQ �O �T �_
�.►:��i:�
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Permit No. •L_+
Received By:
Date Rec'd:
����� ��
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TATE ZIP
-��r
STATE LICENSE # �! y�Q� �� � LEAD CERT NLIMBER �
ADDRESS: !�(p � �P'f� ST C1TY -S�( ��9uLSTATF�%i(JLIP S�'/Od
PHONE C9 ���-2'%Sr— �j/�%�-'� FAX
l�S1NGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION � GARAGE/SHED
❑ BASEMENT FfN1SH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
SIZE
STORIES
❑ WINDOWS
❑ DRAM TILE
❑ OTHER
❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
0 Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
OSoffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
�
HEIGHT
?DyyiC/
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION [NCLUDING DECKS,
ADDITIONS & PORCHES SUBMTT:
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 ST[CKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
� �p'�(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�?�y�-�C7 � 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
$
$
$ (�
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Per►nit 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: 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 t's is not a
permit but only an application for a permi a'�ork is not to start without a permit on site; that the work will be in cord e with the
approved plan in the case of all work which quir�s review and approval of plans. //
SIGNATURE OF APPLICANT PRINT NAME DATE +�
APPROVAL INSPECTOR S[GNATURE