P - 44536Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ' �r0 "��
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE ]-1-2011
YOIJR E-MA L DRESS l/��D
��P.<'/ .S�T�
�IOWNER ❑CONTRACTOR
NAME: � � � ! dG
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: CITY�
H'SINGLE FAMILY/NEW CONSTRUCTION
� TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
FAX
SIZE
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
,C�MAINTENANCE/REPAIR ❑ REMODEL[NG
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SID G
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS �Yes �No
OR FOR NEW OPENMGS-DESCRIBE
OPENWG CHANGES &
TYPE OF WMDOW TO BE INSTALLE
OF
0 HOUSE ONI.Y
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
CJ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS ��/
❑ DRAIN TILE
❑ OTHER
HEIGHT
Permit No.:
Received By• " ' ' �
D��' d� � ���� t . �
�wSTAT�/"ZIP SS%�
STATE ZIP
F7'
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed ftoor ptan •
3. l,ist of snuctural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
A.DDITIONS, & PORCHES SUBMIT:
1. Site P�an/Survey showing the existing shvctures.
and proposed project.
2. Two seu of construction pfans
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:
SI� THE 1997 U.B.0 FEE SCHEDULE)
'AL JOB VALUATION $ ^Z �- 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
��►y�
��
�er���
See Back Fage 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: City of Fridley
Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D UNT[L PROCESSED
I hereby apply for a building pei-mit 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
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
a roved ]an in the case o + c� hic r s review and a rovai of la� (,� ,, ) %� J
SpGNATU E OF APPLICAN�3� i�!�� %�� PR NT NAMEp�%(%� /���" DATE '/'���/ I
APPROVAI. TNSPRCT(1R Ci , AT11RF