P - 80963Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � G-�
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
BUILDING
RESIDENTIAL APPLICATION
� OWNER
STATE LICENSE #
�
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
YOUR E-MAIL ADDRESS
Z
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION
� TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE O ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMINGPOOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR . f�REMODEL]
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
❑ HOUSE ONLY
O HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARyIGE
CITY '�U l
� ��
LEAD CERT NUMBER
CITY�
FAX I Z � �2
SIZE
STORIES
WINDOWS
❑ DRAIN 7'ILE
❑ OTHER
SIDING
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA
❑ Aluminum ❑ Trim REMOVED? O YES ❑ NO
❑ Other ❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes �No LS� ATION OF WIN W `�'
OR FOR NEW OPENINGS-DESCRIBE SIZE OF �,�c �.w�P,n �� L Si� Y:
OPENING CHANGES &
Permit No.:�cw��"`��Jr��
Received By:
I�C�f'H 19 A[AI 9 A A�`
�� � . C6 •�
STATE �1� ZIP
A
U
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BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. 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:
��N G THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�C'x�—'LJ �� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ('j f� - L`S � See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �(}(� .001 times the total job valuation
$ (� .0005 x Permit Valuation Minimum or .50
$ $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determinarion)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ .,. Make checks navable to: Citv of Fridlev Attach
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 not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all wor � which quires review and approval of pl s. � �/
SIGNANRE OF APPLICANT _,- '"`�" � PRINT NAME �d rt � �••�-� DATE h
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