P - 37423Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ( 4 � �
SITE ADDRESS l�-/1
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
❑ OWNER
NAME:
STATE
Permit No.:�
Received By: �
CITY OF FRIDLEY Dat��d�I_�,���
EFFECTIVE 1-1-20] 1
_ YOUR E-MA1L ADDItESS C.Q.e S�'OM ('(� MO C�Q. l l�r! �., �i�1s n, CO'�►
�''�
BCSNTRACTOR
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
C[TY
n . Co �'►-�
LEAD CERT
CITY
FAX
SIZE
STORIES
D WtNDOWS
❑ DRAIN TILE
� OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
fa'1V'�AINTENANCE/REPAIR �MODEL[NG
DESCRIBE WORK BEING DONE: `�. c�C � d C�J'c> <<►
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES 2.�__ ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
, ❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
iN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
HEIGHT
STA'iE��IP Sj��,3Z
STATE ZIP.
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor pfan
3. List of struccural members to be used
FOR NEW CONSTRUCTION INCLUDTNG DECKS,
ADDITIONS. & PORCT-1ES SUBMIT:
l. Site Pian/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE ST[CKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERTALS:
(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
$ �!_1.Z'�
$
$
$
$ j
$
$
$
$
$
$ 1 l�-1 � �
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: Citv 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 applicati n 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 o 11 work re i es r�view and approval of p s. y
SIGNATUREOFAPALICANT PRINTNAME �FN1/E'?ff �V��•� �.t. DATE U � �
APPRQVAL [NSPECTOR SIGNATURE