P - 45720Building
Inspections
763-572-3604
'763-502-4977 FAX
DATE ( d- J - I I
SITE ADDRESS U
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PR�iFER'i'i' T'1'i �
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRE S
��.-. �( � d�..- �
❑ OWNER '�ONTRACTOR
NAME: �
ADDRESS: �- �
PHONE: �
NAME: I ,
STATE LICENSE # `i'
ADDRESS: ��"� � _
PJ�ONE_�(� — [�PBtt'— �(�
�.S.I'�L'L£i FAh4ILY; ": E :?� COI�TSTRUCT:O?+i
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDIT[ON ❑ GARAG
❑ BASEMENT FINISH /�ROOF
❑ DECK ❑ SIDING
❑ SWIMM
❑ NEW HOME CONSTRUCTION
Ld'1vIAINTENANCE/REPAIR
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE: _
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
� /�-�-, �-a
Permit No.:
Received By:
Date Rec'd:
A
EAD CERT NUMBER�U ['r � '� ZS
CITY��_STA
FAX
SIZF
STORIES
NG POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
O DRAIN TILE
❑ OTHER
FT
0
BASEMENT REMODELING SUBMIT:
1. 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 seu of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED � NUMBER OF WINDOWS I
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TQ :..L 30B `' ",L:J� TA+��� g
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
(USING THE 1997 U.B.0 FEE SCHEDULE)
� ► Oi�� �� �CCTJPElNCY 'I'Y�E
$ �'�,'I,� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ `'� .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ j�b $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 ( )
$ � a,a, _� Make checks payable to: City of Fridley 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 wark will be in
conformance with the ordinanc s and codes of City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicat' a permit work ' not to start without a ermit o site• that the work will be in accordance with the
approved plan in the case all wh' u and approval of pl . �� � l �/ DATE I d' 1 T_' (
SIGNATURE OF APPLICANT PRINT NAME � F—
APPROVAL INSPECTOR SIGN E
PLEASE NOTE: SE S ARE RE UIRED FOR PLUMBING, �LECTRICAL AND MECHANICAL WORK ;