P - 44351Building BUILDING Permit rto��CO -�} S 1
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY vate xec'd: �(��t c�
763-502-4977 FAX EFFECTIVE 1-1-2010
DATE '� '� YOUR E-MA[L ADDRESS
SITE ADDRESS � � • s
THIS APPL[CANT IS: �OWNER ❑CONTRACTO
PROPERTY OWNER/ NAME:
TENANT ADDRESS: CITY / � � STATE�ZIP''��-��
PHONE: 71�j ��` �� ,
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # EXP DATE
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE ❑ SINGLE FAM[LY/NEW CONSTRUCTION S1ZE
O TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION O GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE: � S
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING 1 r p HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �� ❑ HOUSE & GARAGE 1, Existing FIooT Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed flaor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCI'ION INCLUDING DECKS,
SIDING ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soffit 1. Site Plan/Survey showing the existing strucwres
❑ Aluminum � Tnm and proposed project.
❑ p�e� 0 Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE ST'ICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL N�1�;1�;� AKl�: ifAl�L ViV VALUAl1V1V� 11Vl:LUL11Vli 1riL� l.Vll Vl' LADVK Al\L 1V1A1G111HW:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUA
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$ �� ��5 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ � .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ ' $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ n.. Make checks pavable to: City of Fridle_y Attach
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 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 applicarion 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 ork which r ires revi w and approval of pl s.
SIGNATURE OF APPLICANT '�f 6/.(.i tE A � �Tn ll1��PRINT NAME (� DATE O` Z"i �`�-/