P - 40843Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CIT� OF FRIDLEY
EFFECTIVE l-]-2011
DATE �"a �� p� O�� YOUR E-MAIL ADDRESS
S[TE ADDRESS SI % � �Oi?l��� L�l�^ �/r / � � �'�
THIS APPLICANT IS: j�91�NER ❑CONTRACTOR
PROPERTY OWNER/ 1 N,�tvtE: � R v
TENANT I p,DDRESS: S /
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
,y. i L
Permit No.:L"� ��'"y'�iC�3'�
Received By: � � �� �
Date��t �t� � ���
e�:
vC4 R� �� a7C
/`t N 5 �' � ,
a/�'/ �a`� CITY
PHONE: %a6 3— S7l— l l a rCj
NAME:
STATE LICENSE #
ADDRESS:
CERT NUMBER
CITY
PHONE FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
C] BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK O SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR . � REMODELING
DESCRIBE WORK BEING DONE:
ROOFING
NUMBER OF SQUARES
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
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF
STATEI�I�IP S J� �'/c�
STATE ZIP
FT
BASEMENT REMODELING SU$MIT:
I . Existing Floor Pian
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction ptans
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 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
Totat Due
$
$
$
$
..--$ " — 2 _(
$
$
$ —
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 S Unit (Plans to MWCC for de�ermination)
_�ft + ft = � ft x� $ �— ,� 2�
$450 Cons r ation Plan Review Z"L �S/-�P
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: City of Fridley Attach Stipulatio�
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 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 of all ork which re uires review and approval of plans.
SIGNATURE OF APPLICANT ��^ �.�+.-��. PRINT NAME DATE
APPROVAL INSPECTOR SIGNATURE � 1 i`. .:�./_ ., I�-,
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