P - 35812Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �
SITE ADDRE S CO
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBM[T A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY /�
EFFECTIVE 1-1-2011 .� 1 _ 1e
YOUR E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
Permit No.: �� � ��
Received By:
D�����.
ADDRESS: �o'ZH1 �G�i�!(30.r1 S � .iU_�CITY lCr� STA
PHONE: %C �i .S�i� ? gS %
STATE LtCENSE # n�O Io 39'.'YdO LEAD CERT NUM
ADDRESS: � %%Sv .SDI'�AS7✓I 31� /lI � CITY
�S[NGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH '6Q ROOF
❑ DECK ❑ S[DING
TYPE OE WORK: � NEW HOME CONSTRUCTION ❑ ADDITION
'9�MAINTENANCE/REPAIR ❑ REMODELING
D6SCRIBE WORK BE[NG DONE: E. a
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES a�. �,HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED S[ZE: � DETACHED GARAGE
PROPOSED HEIGHT:
,�ID[NG
❑ Vinyl
❑ Aluminum
❑ Other _
W[NDOWS
1N EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE [NSTALLED
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE) ,
�Soffit
O Trim
❑ Fascia
LOCAT[ON OF WINDOWS
❑ DRAIN TILE
O OTHER
iM+•" l
�
F7'
�pc�'�"�'NT REMODELING SUBMIT:
i . Existing Floor Pian
2. Proposed floor pian
3. List of structural members w be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
AnDiTInNC Xr FC1R('HF$ SUBMIT:
i. Site PIaNSurvey 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.
TOTAL JOB VALUA
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Suroharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tot�l Due
ANCY
$ ,Z See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 rimes the total job valuation
$ .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 ( )
� ''1 ,(p Make checks payable to: City of Fridley Atta<
THIS IS AN APPLICAT[ON 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
petmit 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 wor , w�equires review and approval of pla..ns�. /% DATE o� 7
S[GNATURE OP APPUCANT � �� _ _ PRINT NAME_(� �
SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK