P - 44116Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 1(]I I 1/ I O�U � �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENAIVT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-M 1L ADDRESS
1�G� ��, f i r e:� i(/
❑ OWNER L�ONTRACTOR
,. ��( vwi. � i� c.
ADDRESS: ` p� f
PHONE; �p7 S ^ � / "
STATE LICENSE #� au �� � yG
ADDRESS: 7
PHONE '0 �! �Yd-�
INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH `�,[tOOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �2EMODELING
DESCRIBE WORK BEING DONE: �-
SIZE OF [MPROVEMENT LENGTH WIDTH
ROOFINC �� �nUSE & GARAGE �''s � e�
NUMBER OF SQUARES
J"'^
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
I IN EXISTING OPENINGS OYes �No
j OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
! TYPE OF WINDOW TO BE INSTALLED
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
CERT
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
Permit No.:
Received By:
� . -' :,` � � �
ATF,/�GIP
A
�
BASEMENT REMODELING SUBMIT:
L Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION (NCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
i. 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
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �.'/�LJ See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ �U $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 ( )
$ �1 � Make checks pavable to: Citv of Fridlev Attach Stiaulations
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 a,n application for a permit and work is not to start without a permit on s' e; that the work will be in accordance with the
approved plan in the case of all wor hic equires review and approval of pla . /` o
SIGNATURE OF APPLICANT � PRINT NAME (�(� ATE �
APPR(1VA1. fNSPFCT(1 � �