P - 36744Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � �
SITE ADDRESS �J
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
Kl_C��
.Q[OWNER
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
T= �� d (e�! . �.
❑CONTRACTOR
�
Permit No. � � � � � ��
Received B : ��
Date �C�
ADDRESS: S' I �L •, /P � CITY �� ��� � STATE�.�IZIP ��Z
PHONE: �l z-" F7�lS�' � �YISr �
NAME:
STATE LICENSE # LEAD CERT NUMBER
ADDRESS:
PHONE
�SiNGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
FAX
STORIES /
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
`�XMAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: N� �� /v I�
STZE OF IMPROVEMENT LENGTH y� WIDTH
ROOFING �Y-IOUSE ONLY
NUMBER OF SQUARES � O HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
: SIDING
! ❑ Vinyl
� Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
OSofiit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
STATE ZIP.
� ��f �
HEiGHT SO FT
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION MCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu of construction plans
3. Energy Catculations
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
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �f,S �d,� 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 oavabte to: Citv 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 t understand this is not a
permit but only an applicatio 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 a 1 wor ich r aires review and approval of ��q^ /
SIGNATURE OF APPLICAN PRiNT NAME� h��eP DATE � �
APPROVAL INSPECTOR SIGN RE