P - 39634Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � �i" o�C�-
SITE ADDRESS ( il ��
THIS APPLICANT [S:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICEN5E
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
FERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MA[L ADDRESS r ������
�'1 �r1 �t- +-f� I�its� �
O OWNER ��ICONTRACTOR
- 6 j'�(' �
___ ; � � -� � --��� v c,�, �t-- CITY r � IP
PHONE: ��%�'S "– � / � " 2'�`7J!
NAME:��'l�%� I–fnY���
STATE LICENSE #y � � ��``,,�� �
ADDRESS:�,��� ����r,��
PHONE �i . �C� _ � �.
�iNG[,E FAM[LYMEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTfON
❑ ADDITION ❑ GARAG
❑ BASEMENT F[N1SH ���F
❑ DECK ❑ SIDING
❑ $W[MM
CERT NUMSER
FAX ! lL/ )
SIZE�_
STORIES
TYPE OF WORK: ❑,NEW HOME CONSTRUCTION p REMODELiNG
MAiNTENANCE/REPA[R
DESCRIBE WORK BEING DONE:
SIZE OF [MPROVEMENT
LENGTH WIDTN
ROOFING '[r OUSE ONLY
NUMBER OF SQUARES I�"�,_ ❑ HOUSE & GARAGE
p ATTACHED GARAGE
GARA ES ❑ DETACHED GARAGE
PROPOSED SIZE:
PROPOSED HEIGHT:
ID[lVG
❑ Vinyl
❑ Aluminum
❑ Other
WIN W
[N EXiST[NG OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SiZE OF
❑Sotiit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
❑ DRAIN T1LE
❑ OTHER
�' 'fi� �i
✓
Received By �
Date Rec'd: �
STATE/ i �/ � GIY_
-- � — (� S=�C= c��:
r,�.i�--STAT�ZIP,
i! 1 _ 'i-7 �?
���.cwrr aGnenDELING S�1_BMIT
1. Existing Floor Plan
2. Proposed floor pian
3. List of suuctural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES U�_BP'iIT:
1. Site Plan/Survey showmg the existing structures
and proposed project.
2. Two sets of construction pians
3. Energy Calculations
FOR WINDOWS – PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & NUMBER OF W[NDOWS
TYPE OF WINDOW TO BE INSTALLED
ALL FEES ARE BA5ED ON VALUATION, INCLtiDING TI-IE COST OF LABOR AND MATERIAL :
SCHEDULE)
TOTAL JOB VALU.
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License 5urcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
TtIDe
(USING THE 9 • C�u OCCUPANCY TYPE
$
$ 5ee Back Page for Fee Schedule
$ �. + 65% of Building Permit Fee
$ � .001 times the tota! job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ dv $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ $+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ Make checks a able to: Ci of Fridle Attach
oa u
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge t4►at 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 Con ttruotthe woakswill be un accordancet with�he
permit but onty an application for a permit and work is not to s without a permit on site;
approved plan in the case of all work which r review an pRINTva�Eplans. pATE
SIGNATURE OF APPL[CANT _ , ,
- - -- . ...,.�
✓Al, INSPECTOR SIGNATURE
PLEASB NOTE: SEPA E PERMI ARE QUIRED OR PLUMBING, ELECTRICAL AND