P - 48121Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � `° �'� — I
SITE ADDRESS �2
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
CITY OF FRIDLEY
EFFECTIVE 1-1-20] 1
YOUR E-MAIL ADDRESS
❑ OWNER f�CONTRACTOR
NAME:�
ADDRESS:
NAME: S/\ f<
STf1TE LICENSE #
PHONE (g / C '� `� / �` � / �
�1SINGLE FAMII,Y/NEW CONSTRUCTION
❑ TWO FAMILYINEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS OYes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
.•7
}ffi'.ROOF
❑ SIDING
❑ SWIMMING POOL
❑ ADDITION
I�HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
Permit No.:
Received By:
.. ,� �
i
AT�{ZIP.
,D CERT NUMBER
CITY Cr%r /3t� STAT IP�
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
WIDTH
FT
BASEMENT REMODELMG SUBMIT:
1. Existing Fioor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu 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
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$ _,
:
/�
i��
TERIALS:
See Back Page for Fee Schedule
65% of Building Permit Fee
.00] 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: City of Fridlev Attach
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 perm' an r is no start without a permit on site; that the work will be in accordance with the
approved plan in the case of all w wh' r u' es rev d approval of pl�•_ ������ J�i '/ �/
SIGNATURE OF APPLICANT PRiNT NAME J� DATE
APPROVAL INSPECTOR SIGNA R ih