P - 45761Building
Inspections
763-572-3b04
763-502-4977 FAX
DATE �fi„5,f)'� d 0 - /
SITE ADDRESS��
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
�� ��
BUILDING Permit No.: �rf �� �
RESIDENTIAL APPLICATION Received By:
CITY OF FRIDLEY vate Rec'd: �= _�
F.FFECtIVE 1-1-201 l _ __
YOUR E-MAIL ADDRESS
❑ OWNER
• � r � i�L:l!��1i/JJF��I�s���s�„
• - •. _-1 �t�
CONTRACTOR NAME:y�
SUBMIT A COPY OF gTATE LICENSE #
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS:��
INSURANCE PHONE�%LO�J"
r
PROPERTY TYPE '��NGLE FAMILY/NEW CONSTRUCTfON
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE u r,wi uviv
❑ BASEMEN'f FINISH OOF
❑ DECK ❑ SIDING
TYPE OF WORK: ❑ MA NT6 AN OF/REPAIRTION � EMODEL
DESCRIBE WORK BEING DONE:%P �
SIZE OF IMPROVEMENT LENGTH WII
ROOFIN ❑ HOUSE ONLY
NUMBER OF SQUARES � �HOUSE & GARAGE
GARAGES TTACHED GARAGE
PROPOSED SIZE: DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑Soffit
❑ Trim
❑ Fascia
ATE�ZIp.
LEAD CERT NLIMB�E�` � ' � - - -
CITY fTf'l YY1 I Q{'�_STATE��% 1P.��
_ . .. -� � ,, a, _ '1 u C./ ,. ;�"7 � �
SIZE
O DRAIN T{LE
p OTHER
� �0�
BASEMENT REMODEL[NG SUBMIT
1. Existing Floor Plan
2, Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDIT[ONS & PORCHES SUBMIT':
1. Site PIan/Survey showmg the existing structures
and proposed project.
2. Two sets of construction pians
3. Energy Calculations
WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
IN EXISTING OPENINGS ❑Yes ❑No LOCATfON OF WINDOWS MANUFACTURE STICKER ON WINDOW.
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES & NUMBER OF WCNDOWS
TYPE OF WINDOW TO BE INSTALLED
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
� � . . srr� nc['I JPANCY _ TYPE
TOTAL JOB VALUATION
Permit Fee
plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totai Due
$ , See Back Page for Fee Schedule
$ .�. 65% of Building Permit Fee
$ .001 times the total job valuation
$ � 8/ .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 ( )
Q 1... Make checks payable to• City of Fridley Atta�
THIS IS AN APPLICATION FOR A PERMI7'-NOT VAI,ID 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 code of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only ar► application for a permit d work is not to start without a permit on site; that the work will be in acco�r�dan�e with the
approved plan in the case of al pr which r uire eview and PR NrT Na�l MEPIan�,4�� � DATE
SIGNA7'UREOFAPPLICAN'f t
✓AL INSPECTOR SIGNAT RE
PLEASE NOTE: SEPARATE P S AR REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WO