P - 37480Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ���3��/�
SITE ADDRESS .S�DOD� �
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
THIS APPLICANT IS: � ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NqME:
TENANT _ _ _ _
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
S[ZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES ZQ
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
PHONE: li / %. '� � Y�/ "
NAME: �
STATE LICENSE # U
ADDRESS:
PHONE ,i� 2[ � '
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
CITY
Permit No
Received By:
� o ��.�;
0 G�
Date 1�����€�� Q
�
LEAD CERT NUMBER
��CITY p" � �/�STAT Z1P S.S�
FAX
S [ZE
STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ��'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODEL[NG
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
LENGTH
❑ HOUSE ONLY
�HOUSE & GARAGE
� ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINI
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I . Exis[ing Ploor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDTNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the exis[ing structures
and proposed proiect.
2. Two sets ofconstruction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $ � 0�� � G HE 1997 U.B.0 FEE SCH OCCU ANCY TYPE
Permit Fee
Pian Review
Fire Surcharge
Surcharge
License Surcharge
I SAC Charge
Curb Cut Escrow
Erosion Control
I Park Fee
� Sewer Main Charge
! Total Due
3
$
$ �
$ 3`
$
$
$
$
$
$ a W a'
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 Residentia( 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 aavable 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 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 a o IEwh' equires review and approval of pl '✓��� . /
SIGNATURE OF APPLICANT _���� PR1NT NAME�/� //L(// � DATE �( iZ ,����
APPROVAL INSPECTOR SIGN RE