P - 47256Building
Inspections
763-572-3604
763-502-4977
DATE��
SITE 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:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MAIL ADDRESS
❑ OWNER '�CONTRACTOR
NAME: Qy 'Z�i-�,
ADDRESS: �' 7 l �Z
PHONE:
CITY
Permit No.: `�iV I� c�� ��j
Received By: rn �w l'
��'�e�J�V Q 1 2��1°�
STATE /�'�NZIP S,S 3
NAME: i��f'n i�,� �G'i Z-�T �-F.1� ���1�w�.f1� -
STATE LICENSE #_��� � LEAD CERT NUMBER
ADDRESS: �(�J� �d"�.i'� 5 �' CITY ,/�!� STATE ZIP�_S�
PHONE �j I�Z �I G � "12,�i FAX �%� �� Z c�Eit..
�,�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH �1ROOF
❑ DECK ❑ SIDING
❑ SWIMM
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEiNG DONE:
SIZE OF IMPROVEMENT ��
ROOFING
' NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
[N EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
�-- �ck;�
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
ING POOL
❑ ADDITION
►�1 REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
WIDTH /� HEIGHT
FT
BASEMENT REMODELING SUBMIT
I. Existing Floor Plan
2. Proposed floor plan
3. List of struc±ural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT•
l. Site Plan/Survey showing the existing structures
and proposed proiect.
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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
� l t�.L.7
$
$ � , i`�I
$ a.c�—
$ �,
$
$
$
$
$
$ . �•.
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: City of Fridley Attach
THIS IS AN APPLICAT[ON 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 application for a e' and wor s ot to start without a per 't on site; that e work will be in ac or nce with the
approved plan in the case of all work �ch r i e w and approval of plan ��
SIGNATURE OF APPLICANT PRINT NAME ��t'/ � ��� DATE � I
APPROVAL INSPECTOR SIGNATURF