P - 48356Building
In�pections
7,�3-572-3604
763-502-4977 FAX
DATE '�� ° � -� � l
SITE ADDRESS �
TH[S APPI,ICANT IS
PROPERTY OWNER/ I NAME
TENANT �_
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
�����
OWNER ❑CONTRACTOR
G' l {� �' �� g,� y
lS: � �'Lh ��Y�C.d i;5 �"�� �y�C.�UL� CITY
/_ i� J �i5 _ A � /_ SI
STATE LICENSE #
ADDRESS:
PHONE
O SINGLE FAMILY/NEW CONSTRUCTION
O TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
LEAD CERT NUMBER
FAX
SIZE
❑ ADDITION
C%IREMODELING
Q HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes �No LOCATION OF W DQ� S
OR FOR NEW OPENINGS-DESCRIBE SIZE OF S�l.� .Y
OPENING CHANGES 8c
Permit No.
Received By:
Date Rqei�,
STA
CITY STATE ZIP
u WiNllUWS gJ r�,�S
❑ DRAIN TILE
❑ OTHER
HEIGHT �%d
BASEMENT REMODELING SUBMIT•
L Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS, & PORCHES SUBMIT:
1. Site Pian/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.
_TYPE OF WINDOW TO BE INSTALLED .��%1/�.C,S.S NUMBER OF WINDOWS �
ALL FEES ARE BASED ON ALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
IN�E 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule �
Plan Review $ $ E 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$24 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
8ewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ -�L�'� C(� Make checks payable to: Cit of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and cknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and odes of City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio f a e it n wo is not to start without a permi on site; t t th �,ork will be i accordanc with the
approved plan in the case of a v� r � i vi and approval of pl , s + �
SIGNATURE OF APPLICANT I � PRINT NAME "�— � DATE �
APPROVAL INSPECTOR SIGNA
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