P - 45382Building
Inspections
763-572-3604
763-502-4977 FAX
DATE `' �— � r / �
SITE ADDRESS K
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
BUILDING ����
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE ]-1-2011
' o,� T
�OWNER
NAME: �
ADDRESS:
PHONE:
NANiE: � `'
YOUR E-MAIL ADDRESS
❑CONTRACTOR
CITY
Permit No.;,t�l! '
Received By: �
Date Rec'd: � J,
STATE ZIP
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: CITY STATE ZIP
PHONE pp}{
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION � ❑ GARAGE/SHED � WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ STDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTfON ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING OUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES � �HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
' WINDOWS
! [N EXISTING OPEN[NGS ❑Yes ❑No
j OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
� TYPE OF WINDOW TO BE INSTALLED
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT
1. Site Plan/Survey showing the exis[ing structures
and proposed project.
2. Two sets of construction 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:
� /(U ING T� 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ (o r-- OCCUPANCY TYPE
Permit Fee $ ��, /!> See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ /, .001 times the total job valuation
Surcharge $ ��' 3 .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $• Agreement necessary O Non Necessary O
' Total Due $ a Make checks payable to: City of Fridley Attach Stipulations
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 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�l rk w' h requir.�s revi , and pproval of pl y.,, �j /�
SIGNATURE OF APPLICANT '/ J �J j �R[NT NAME �jyt �i� �e�I6G /`� DATE l i�',
APPROVAL INSPECTOR SIGNATURE �—�C . i _ .