P - 35964Building
Inspections
763-572-3604
763-502-4977 FAX
DATE t't "
SITE ADDRESS 1lJ [
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
THIS APPLICANT IS; ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: t�i lE� r
TENANT ______ �� .,.. .n.�..a ..� �. ..�. .
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
I' • . ,. � •
r r
STATE LICENSE
CEIiT
Permit No.:
Received By:
FAX �l .5 0l^ �-! J o<:
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FANIILY/NEW CONSTRUCTTON STORIES�_
❑ ADDITION ❑ GARAGElSHED ❑ WINDOWS
❑ BASEMENT FINISH �ItOOP ❑ DRATN TILE
❑ DECK ❑ STDING ❑ OTHER
❑ SWIMMING POOL
�NEW E30ME CONSTRUCTION ❑ ADDTTION
MAINTINANCE/REPAIR ❑ REMODELING
. n r _ s. w C ...- _ �... _ ,.
ROOFING �
NTJMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT: _ ___
STDING
O Vinyl
❑ Aluminum
❑ Other
WIDTH
❑ HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACfTED GAT2AGE
�DETACHED GARAGE
0
L
�
FT
BASEMENT REMODELTNG SUBMTT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the e�sting suuctures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTTNG OPEIVING5 ❑Yes ONo LOCATTON OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENTNGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WTNDOW.
OPENING CHANG�S &
TYPE OF WINDOW TO BE INSTALLED NIJMBER OF WIN'DOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ S�C4 O E; , a0 OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb G�t Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of BuiIding Pernut Fee
.001 times the total job valuaxion
.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
�greement necessary ( ) Non Necessary ( )
ake checks uavable to: Citv of Fridlev Attach
THTS IS AN APPLICATION FOR A PERMTT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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 ap lication 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 c e f all work whi •equir r view and approval of plans. !� � � f
SIGNATURE OF APPLTC ��� PRINT N I 1\ ��-01— /
APPROVAL INSPECTOR STGNA RE