P - 35968Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � �V
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EPFECTIVE 1-1-2011
� � r
❑ OWN R
NAME:
ADDRESS:��
PHONE: ''
NAME:
STATE LICENSE # _
YOUYR� E-MAIL ADDRESS
1�W �1
�CONTRACTOR
� � � CITY
1 O1'�
►CERT
r
ADDRES3: "1 / � a t CITY�
PHONE � � FAX
SiNGLE FAMILY/NEW CONSTRUCTION S[ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
O BASEMENT FINiSH ❑ ROOF DRAIN TILE
� DECK ❑ SIDING � OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOMECONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DON . �� q� � �,
SIZE OF [MPROVEMENT LENGTH WIDTH
ROOFING � ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl �,G;�
� Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�ISoffit
°O Trim
�J Fascia
LOCATION OF WINDOWS
NUMBER OF
ld
Permit No.
. . . -. : r�
.
�
� , • '; t,, � � 1
.
A
A
F7'
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:
I. 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 FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�� � OCCUPANCY TYPE
Permit Fee $ �d, 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 $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC far determination)
Curb Cut Escrow $ 8+ 6 ft = ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Pazk Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Tota! Due $ •, Make checks pavable to: Citv of Fridlev Attach Stii
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D UNTII. 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 1 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 all o �wh��' �h r�equires review and approval of p s. h
SIGNATURE OF APPLICANT e�l ����--,�=�. � PRiNT NAME ��C�` {..� �� l� DATE �% �%� ( I
APPROVAL INSPECTOR SIGNATURE