P - 48050Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ��(p y O[ O� I
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TEI�TANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
', DESCRIBE WORK BEING
IMPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
YOUR E-MAIL ADDRESS
� f'l d OV' �( � � -
�WNER ❑CONTRACTOR
ADDRESS:
PHONE:
STATE LICENSE #
ADDRESS:
PHONE ppJ{
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK ❑ SID]NG ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�A�IAINTENANCE/REPAIR ❑ REMODELING
G�N
�IC= CITY_
l-3yo
EAD CERT NUMBEF
CITY
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
Tu
❑ HOUSE ONLY
�i-IOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
Permit No.��►
Received By: `
Da 'd:.�����
STATEY�� ZIP
ATE Z[P
5�
FT
BASEMENT REMODELING SUBM[T
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
__ FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT
I. 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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
� Permit Fee $ See Back Page for Fee Schedule
�, Plan Review $ 65% of Buifding Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ j �.0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
'Total Due $ ;�. Make checks payable to: Citv of Fridlev Attach
lations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 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 not to start without a permit on site; that the work will be in accordance with the
approved plan in the case pf vork_ hi r quires rev}ew and approval of pl / ,^,�/ %/>
SIGNATURE OF APPL[CANT i ����pRiNT NAME �c�( �/; � �i� ,,��q kcj,�i DATE (U � �i "� �I `
APPROVAL INSPECTOR SIGNT'iIJRE .� �