P - 35115Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS _�
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20] f
YOUR E-MAiL ADDRESS
❑ OWNER [�ONTRACTOR
PROPERTY OWNER/ I NAME:�
TENANT ApDRESS: � ,
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING D
PHONE:
NAME:
��
��
Permit No.: �� � � 1 Z���'
Received By: .
Date Rec'd:
STATE LICENSE� # -` LEAD CERT NUMBER.� /�/ .�
ADDRESS: C��Y"� � ���� / / 1/ CTTY '''�`�� �
PHONE �� � " N'2 % � (��. F� FAX �t� 7 " y- 2 �' "_
0
❑ SRJGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED O WINDOWS
❑ BASEMENT FINTSH m ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING � OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTiON ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELRJG
ROOFING `Z
NUMBER OF SQUARES�_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SID[NG
❑ Vinyl
❑ Aluminum
� Other
❑ HOUSE ONLY
� HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
� Fascia
WINDOWS
IN EXISTING OPENINGS OYes ❑No IACATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENIIJG CHANGES &
ALLED
NUMBER OF
HEIGHT
ATE�IP,
5 '� /
ATEA11✓ ZIP,
I��
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDTNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu of consuvction plans
3. Energy Calculations
FOR WRJDOWS — PROViDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�r ,�,_Q,�IN��TJ3F� 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION ,
Permit Fee.
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � � 1. 25 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ S .001 times the total job valuation
$ O .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 ( )
$ � � I Make checks uavable to: Citv of Fridlev Attach Sti�ulations
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 acc/�nce with the
approved plan in the case of all work which requires r iew and �foval of pla /
SIGNATURE OF APPLTCANT PRINT NAME �vl� y �i�ki,,,�DATE ���/I/
APPROVAL INSPECTOR SIGNATURE