P - 47805Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � - �
S[TE ADDRESS �� ,�L-
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT(VE i-I-201 l
YOUR E-MAIL ADDRESS
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`� OWNER ❑CONTRACTOR
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2ESS: ( 2. Gr r��0,y»� � r•�.�' CITY
JE: .� �i - 3 �—� �/_� �� I(
NAME: j'
STATE LICENS�'�
ADDRESS: ;
PHONE
�CSINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ,�ROOF
� DECK ❑ SIDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODEL
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING x
NUMBER OF SQUARES _�_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
LEAD CERT NUMBER
CITY
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
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ATE�ZIP��
STATE ZIP
FT
BASEMENT REMODELING SUBMIT
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
❑Soffit ADDITIONS & PORCHES SUBMIT
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
WINDOWS 2. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ONo � LOCATION OF WINDOWS 3 Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS - PROV[DE U-VALUE AND
OPENING CHANGES & MANUFACTURE STICKER ON WINDOW.
I TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
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 TVPF
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 Pennit 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 payable to: Cit of Fridle Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 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 of all ark which requires review and approval of plans.
SIGNATURE OF APPLICANT �� PRINT NAME � � �� � � �� � �� , DATE C - �' - !�
APPROVAL INSPECTOR SIGNATURE %/