P - 48506Building
I���ections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-20ll
Permit No
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DATE P�% YOUR E-MAIL ADDI2ESS �v'�/''� ��"'�°�l'��c-{���(/� „Cj(�.N�.
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THIS APPLICANT [S: �'AWNER ❑CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF [MPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
'� Other Sf(�¢f�Q
ADDRESS:�pL �j/�7'�.T�ii� }�.,Q, � CITY�./��+ STATE�N ZIP�,_a�"�Z
PHONE: �fo ��i � �1%g ���4' %
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: CITY STATE Z[P
PHONE
1�,iNGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH ❑ ROOF
� DECK ❑ SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION �DDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
;: /�/E� �.Pr,� �iQJ'' Q
LENGTH ! ` WIDTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
', WINDOWS
', IN EXISTING OPENINGS ❑Yes ❑No
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
' TYPE OF WINDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
FAX
❑ DRAM TILE
❑ OTHER
HEIGHT
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,
ADD[TIONS, & PORCHES SUBMIT:
l. 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.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�j SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $'�/ �d� ` 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
$ �'I�LS
$
$
$ `U
$
$
$
See Back Page for,Fee Schedule
65% of Building Pern`�it 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 pavable to: City of Fridley
Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D UNTIL PROCESSED
I hereby apply for a building permit and I ackn wl e that t information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City Fridl and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for it and work is ot start without a permit on site; that the work will be in accordance with the
approved plan in the case of a h ir re e d approval of plans.' -- �/ 1��
SIGNATURE OF APPLICAN P T N E�G�/ �JGyL��TE � fI
APPROVAL INSPECTOR S[G E j � E���
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