P - 47345Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /
SITE ADDRE S _
TH[S APPLICANT IS:
0
� `
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS �--
❑ OWNER �CONTRACTOR
PROPERTY OWNER/ I NAME:_
TENANT p,DDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK
J
STATE LICENSE #
ADDRESS: !v
Permit No.:
Received By:
Date Rec' d: _ _ _ _ ,
ATE��I Z[P�
v�e a/►�n � l,� I— ��... � c.
:AD CERT NUMBER
j�/K�. CITY � f" I�� �'� STATE�ZfP�s.�
PHONE �F�3 % � � � U / �C FAX
�SINGLE FAM�ILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRA[N TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMM[NG POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
I'�'TvtATNTFNANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
��7�I
ROOFING �� �
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
W INDOW S
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
�rvnv nF u�n.innw Tn RP rNCTA1.I.F.T]
C7����T�
LENGTH
'��[-IOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
FT
BASEMENT REMODELING SUBMIT:
L Exis[ing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
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 STICKER ON WINDOW.
. .. .. .,. .....-- - - - --
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
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 ( )
Make checks pavable to: City of Fridley Attach
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tntal nue
$ a � •7i�7
$
$
$ L 7i_
$ `j
$
$
$
.:._
lations
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 11 work�whi requires r view and PRN T NAMEp�n�i-v / C� 1�.�� �'�%'y %� DATE G%6 0�- ��
SIGNATURE OF APPLICANT �_
APPROVAL INSPECTOR SIGNATURE
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