P - 41406Building
Inspections
763-572-3604
763-502-4977 FAX
, DATE �� ( �
SITE ADDRESS �`�„
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MA1L ADDRESS
❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME:
TENANT pDDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMTT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
S
crTv
STATE LICENSE # L-U(�_.S� LEAD CERT NUMBER_
ADDRESS: b����j Z�f'�f ��� r�� CITY�
PHONE (n I Z'��� ��QI FAX %�p'�
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRllCTION STORIES
Q ADDITION D GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING j�"OTHER
❑ SWIMMING POOL �C/
❑ NEW HOME CONSTRUCTION ❑ ADD[TION
�v1A1I�TE�iAI�E/REPAIR _ ❑ REMODELING t-�
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 WINDOWS
Permit No.
Received By:_
���. P
�
.� �IP�
��
HEIGHT � / SO FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDTNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction pians
3. Energy Calculations
FOR W[NDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
� (USI�IXG THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $���9�Yj 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
$
$ i� 0
$ <�
$ ��
$
$
$
$
$
$ —
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 payable to: City of Fridley Attach
THIS IS AN APPL[CATION 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 c s o e C' o; ridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f a ' not to w' ut a permit on site; that the work will be in accordance with the
approved plan in the case of all and appr al f plar����, A/��„'�`Y/�'� /"J`�� � j
SIGNATURE OF APPLICANT PRI .�T( ' n•� `7
APPROVAL INSPECTOR SIGN URE