P - 35255Building
Inspections
763-572-3604
763-502-4977 FAX
DATE %
SITE ADDRESS �
TH[S APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSUR.ANCE
PROPERTY TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201i
� �/ YOUR E-MAIL ADDRESS
� ��s�r�/ SI . �f� ��,:
�OWNER ❑CONTRACTOR
,v,�E: an u �m c�t'
STATE LICENSE #
CITY
LEAD CERT NU
ADDRESS: CITY
PHONE FAX
SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES . /1is
PERMIT TYPE � �DITION
O BASEMENT FINISH
❑ DECK
TY.PE OF WORK: ❑ NEW HOME CONSTRUCTION
,B.DAAINTENANGE/REPAIR �
DESCRIBE WORK BEING
ROOFING � /
NUMBER OF SQUARES 3'n
GARAGES
PROPOSED SIZE:
PROPOSED TiEIGHT:
SIDING
❑ Vinyl
❑ Atuminum
C] Other
i0,(200F ❑ DRAIN T]LE
❑ SIDTNG ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
, ❑ REMODELING
�OUSE ONLY
G�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�F
Permit No.:
Received By:�li
Dat����d� ��-
L! _.SZ
� �Z
"i�ZIP � _�3 Z
ATE ZIP.
�
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan `
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1• Site PIanJSurvey sfiowing ihe existing structures
❑ Fascia
and proposed project.
2. Two seu of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes C1No LOCATION OF WINDOWS FOR WMDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER O1J WINDOW.
OPENING CHANGES &
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)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
P[an Review
Fue Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$
$
$
$ . „ — -
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times 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 ( )
Make checks payable to: Cityo uf Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESS6D
I hereby apply for a building permit and 1 actcnowiedge that the information above is complete and accurate; that the work wfll 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 it and work is not to start without a pe 't on site; that the work will be in accordance with the
approved plan in the case of all wor ic re�ires review and approval of plans �/' /
SIGNATURE OF APPLICANT _.P.RINT NAME �� 1�Y�Ci ( DATE �Z 1
APPROVAL INSPECTOR SIGNATURE