P - 47735Building
Inspections
763-572-3604
763-502-4977 FAX
DATE� I�
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL
�_
❑ OWNER
NAME: �
ADDRESS:
NAME:��
STATE LICENSE #
ADDRESS: � I DD
�,SINGLE FAMILY/NEW CONSTRUCTION
� TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH �'ROOF
O DECK ❑ SIDING
❑ SWIMM
EAD CERT NUMBEF
� CITY�
FAX �� ��J ' I �
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � a
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ^ /� ❑ HOUSE ONLY
NUMBER OF SQUARES d' �HOUSE & GARAGE
GARAGES r�ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
HEIGHT
Permit No.:� �l
Received By:
�.-�- , !�
j = 1
ATE�ZIP���
ATE�IP � � ��
FT
BASEMENT REMODELING SUBMIT
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
�Soffit ADDITIONS. R PORCHES SUBMIT
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
WINDOWS 2. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS 3. Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROVIDE U-VALUE AND
OPENING CHANGES & MANUFACTURE STICKER ON WINDOW.
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 SCHEDULE)
TOTAL JOB VALUATION $ O(�(�i1PA�vrv TVDL'
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due `
$ ��� .�� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
_ $ � �_ .0005 x Permit Valuation Minimum $5.00
$ �"i � $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: Citv of Fridlev Attar
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 application for a permit and work is ot to start without a permit on site; that the work will be in accordance with the
approved plan in the case r ich re u e' d approval of pla.�� � /
SIGNATURE OF APPLICANT PRINT NAME_� f, i���� !'� _DqTE �D � I`�l I I
APPROVAL INSPECTOR SIGNA RE
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHA1vICAL WORK