P - 35502Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � -l8 - �
SITE 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:
DESCRIBE WORK BEING
R FING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-i-2011
YOUR E-MAIL ADDRESS
❑ OWNER
_.
Permit No.: � L:� �` "7 �=�`
Received B�y: �`���`�
D��Rec�d:
�� Gzwai:�` 1. ��
ADDRESS: CITY STATE ZIP
PHONE:
NAME: r. K��[1 � �
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: ���OS �P,(NSt91,1 V�Ci.�/ n(� CITY �"r,Z`�_ (./ _ STATE�ZIP �T7y3�
PHONE �� 3- a 3��_1�5� � FAX ---- �
O SINGLE FAMILY/NEW CONSTRUCTION SIZE
L�TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED WINDOWS
� BASEMENT FINISH ❑ ROOF DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUGTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �(REMODELING
SIDING
❑ Vinyl
O Aluminum
❑ Other
WINDOWS ,/
IN EXISTING OPENINGS P��'es C]No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE iNSTALLED Vlp
ALL FEES ARE BASED ON V.
COTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
O HOUSE ONLY .
O HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
���N�� �
NUMBER OF V�
/�
BASEMENT REMODELING SUBMIT•
1. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT•
1. Site PIaNSurvey showing the existing structures
and proposed project.
2. Two sets of constrvction plans
3. Energy Caiculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
UATION, INCLUDING THE COST OF LABOR AND MATERIALS:
NG THE 1997 U.B.0 FEE SCHEDULE)
OCCUPANCY TYPE
$
$ 2Q
$
$
$
$
$
$
$
See Back Page for Fee Schedule
b5% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residenrial Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridlev
Attach Stipulations
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 p rmit an 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 1 rk hi�c r ires review and approval of pl ns. � �
SIGNATURE OF APPLICANT 1 PRINT NAME ��\I I� ��� DATE �"�� I I
APPROVAL INSPECTOR SIGNA RE
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