P - 45386Building
Inspections
763-572-3604
763-502-4977 FAX
DATE !�
SITE ADDRESS
THIS APPLICANT [S:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
��
❑ OWNER
NAME:_
ADDRESS:
PHONE:
R E-MAIL ADDRESS
��
�
��
STATE LICENSE # .-� ��; ��` ) � ��_
ADDRESS: ��j �" '-�, v ,�.�s • �t,;,
. . .. '
PHONE -, .. � � .... ,, � FAX
INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT F[NISH �OOF ❑ DRAIN TILE
❑ DECK ❑ SiDING ❑ OTHER
❑ SWIMMING POOL
❑ HOME CONSTRUCTION ❑ ADDITION
AINTENANCE/REPAIR ❑ REMODELING
Permit No.:
Received By:
Date Rec'd:
s��:�e i�l��v�, 2 � � %
,�. �"1.�"�i�+�
CiTY � 1 "" � �' STAT�
_ -'-�' � � � �;� . �� ��
I�EAD CERT NtIMBER F
� _-_ _ CITY :a�T i�l '� STA'
DESCRIBE WORK BEING DONE:_�j
SIZE OF IMPROVEMENT
ROOFING ,�
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
� ❑ Other
� WINDOWS
I IN EXISTING OPEN[NGS ❑Yes ❑No
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
� TYPE OF WINDOW TO BE INSTALLED
<'ld'HOUSE ONLY
�- OUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
OSoffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
WIDTH ° HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION iNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL N'N:LS AR�; BASEU ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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 $ � .0005 x Permit Valuation Minimum $5.00
License Surcharge $ � 8 $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 () Non Necessary ()
Total Due � ,, Make checks payable to: City of Fridley 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 al whi r ' eview� approval of pla �. ' r
SIGNATURE OF APPLICANT k:��`�.� ��� ���� ' PRINT NAME e)1`t2CiQIl �� i��ATE� r��1
APPROVAL INSPECTOR SIGNATURE 7�
�