P - 44885Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ��
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
MSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
BUILDING
Permit No. �� �
RESIDENTIAL APPLICATION Received By:
CITY OF FRIDLEY nate ��,'�:���
EFFECTIVE 1-1-2011
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ADDRESS: %3 ,
PHONE: %G�"
�CONTRACTOR
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TATE�ZIP
STATE LICENSE #� G 6 z�%�L� LEAD CERT NUMBER ��A
ADDRESS: 3�QI EL,v� S� CITY �$r.�.fii,��� STATE!'iIUZtP SrS6
PHONE �%� �'" C� � % — �.� Z % FAX 7� - yy�- �a S
INGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTION STOR[ES %
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN T[LE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODEL[NG
ROOFIlVG ?
NUMBER OF SQUARES JZ
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
I WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
� HOUSE ONI.Y
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
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:
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.
! TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ j�J.LS
$
$
$
S
$
$
$
$
$
See Back Page for Fee Schedule
65% of Buifding Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.40 (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 ( )
Make checks payable to: City of Fridfey Attach
THIS IS AN APPLICAT OR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I ac owl g that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes t Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for e a is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of or ch s revie�and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME__ ��G�� ���►SQf'� DATE � �,a )
APPROVAL INSPECTOR SIGNA E �