P - 35809Building
Inspections
763-572-3604
763-502-4977 FAX
DATE d ' l �
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 BEMG
SIZE OF IMPROVEMENT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
OWNER
STA
PHONE
E-MAIL ADDRESS �
r
» ` � �—�
,W CONSTRUCTION
CONSTRUCTION
CITY
Permit No::
Received By:
Date Rec'd:
'ATE ZIP
�D CERT NUMB
CITY Q ,_STATE�I�IP ��
FAX
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑� R�O2� ❑ DRAtN TILE
❑ DECK �'SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR B'1�EMODELING
HEIGHT _ SQ FT
ROOFING ❑_� H�. SE ONLY BASEMENTREMODELING SUBMIT•
NUMBER OF SQUARES y�'ECOUSE & GARAGE I. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2: Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
S� �ny� � ADDITIONS & PORCHES SUBMIT•
❑ Aluminum ❑ Tf�m _ 1. Site PlanlSurvey showing the existing structures
❑ Other O Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Galculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
SI G THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ _ '� OCCUPANCY TYPE
Permit Fee $ t��j 3'�' See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire 5urcharge $ � .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ ��Q $5.00 (State Licensed Residential Contractors)
SAC Chazge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6�} = ft x$25= $
I Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ `
� Make checks payable to: City of Fridley Attach
lations
THIS IS AN APPLICATION FQR 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 f r a perm' wo k is not to start without a ermit on site; t, t the work will be in accordance with the
approved plan in the cas or ic r�quire r vi and approval of pians.
SIGNATURE OF ANT PRINT NAME � l � �� 1�
APPROVAL IN CTOR SIGN TE �'�--,—