P - 44202Building
Inspections
763-572-3604
763-502-4977 FAX
DA� iv �,
STTE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BERVG DC
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MA[L ADDRESS
❑ OWNER �CONTRACTOR
ADDRESS:�� � I vR� aC /_ L- `f �7 �1TY
PHONE: �li 3^ 7� li "%b 33
STATE LICENSE �
ADDRESS: I �/I �S �/l,�-�,�
PHONE lo � 2 _ �- � �% ." � � 1
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION � ❑ GARAG
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
O NEW HOME CONSTRUCTION
SIZE
❑ ADDITION
❑ REMODELING
I,J HOUSB ONLY
❑ HOUSE 8c GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
Permit No.:1 [,lG c'�;
D� l�C �1
'
STA
EXP DATE
_CITY��Lpnv�� STATF�ZIP��f
❑ DRAIN TILE
❑ OTHER
HEIGHT
FT
RASEMENT REMODEL[NG SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural membersto be used
3IDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl OSoffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim i• Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of conswction plans
WINDOWS 3. Energy Caiculations
IN fiXISTING OPENINGS �Yes ONo LOCA1'ION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRiBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENIING 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 SCAEDULE)
'OTAL JOB VALUATION $/, ODD .�i� ___ ___ OCCUPANCY TYPE � r v,;�/�
Permit Fee
Plan Review
Fire Surcharge
Surchacge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
'$ �$�S See Back Page for Fee Schedule �`1 �
$ 65% of Building Permit Fee '�v` ,�
$ .001 times the total job valuation ,� n
$ � .0005 x Permit Valuation Minimum $.50 �'�� ' `
$ ' $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
S ft+6ft= 8x$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � _ Make checks aavable to: Citv of Fridley Attach Stiuulati�
THIS IS AN APPLICATION 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 ord' e d codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an ap cation f a perm d work is not to start without a permit on site; that the work wil! be in accordance with the
approved plan in the c e of all ork whic quires review and approval of
SIGNATURE OF APPLICA D`�' PRINT NAME t T ATE O