P - 35756Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE YOUR E-MAIL ADDRESS
SITE ADDRESS � �� �U%P/2/_tti ��
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
ADDRESS:
PHONE:
NAME: ( . �
STATE LICENSE #
ADDRESS: �
�INGLE FAMILY/NEW CONSTRUCTIi
Q TWO FAMILY/NEW CONSTRUCTION
O BASEMENT FTNiSH
❑ DECK
❑ SIDING
❑ SWIMMING POOL
v,r!
CfTY
PeTrilli NO.: r �,� � V � ,
Received By:,T�;� �L�_
D���c'�#�:+� � � c� � � � �
STATE ZIP
G�tlS � �
LEAD CERT NUMBER
''�CITY.��'_7iL.////� 7� STATE�%,IP��
FAX
SIZE
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
AINTEN,ANCE/REPAIR � ❑ REMODELING
DESCRIBE WORK BEING E: — �S
SIZE OF [MPROVEMENT GENGTH WiDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES _�� ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ wirr�ows
❑ DRAIN TILE
❑ OTHER
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
� SIDIN FOR NEW CONSTRUCTION INCLUDiNG DECKS,
!❑ Vinyl OSoffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum � Trim 1. Site Plan/Survey showing the existing structures
O Other O Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
tN EXISTMG OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WiNDOWS – PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE C4ST 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
Paxk Fee
Sewer Main Charge
Total Due
$ (/�f �.OiS 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 ( )
$ I � Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 ermit 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 al o whic ' es review and approval of pla
SIGNATURE OF APPUCANT PRINT NAME �, �� ? �(�L�DATE � � � f
APPROVAL INSPECTOR SIGNAT , •--�--