P - 43791Building
Inspections
763-572-3604
763-502-4977 FAX
DATE !� ' / "
SITE ADDRESS ��
7'HIS APPC.ICANT IS:
PROPERTY OWIYER/
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 ADDRESS
❑ OWNER °�ONTRACTOR
ADDRESS: ,'��j � �u c� u'z _ ��r.
PHONE: !Gj`, - S7 I � g�
STATE LICENSE # �( �i -]
ADDRESS: t �� � I
PHONE liFB,� ���S � g� C� O
I�SINGLE FAMILY/N
❑ TWO FAMILYMEW CONSTRUCTION
O BASBMENT FINISH
❑ DECK ❑
h
CITY
CERT NUMBER
SIZE
STORIES
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: -
SIZE OF IMPROVEMENT LENGTH WIDTH
R FING I �HOUSE ONLY
� NUMBER OF SQUARES !'�D . �O ? ❑ HOUSE & GARAGE /'�
GARAGES ❑ ATTACHED GARAGE ��
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
I I
❑ Vinyl �Soffit
❑ Aluminum ❑ Trim �
Q Other ❑ Fascia
�
❑ DRAIN TILE
❑ OTHER
Permit No.:L� � ('� � �
�V���
Date Rec'd:
STATE/" VV ZIP.
r- � - �
�� STATE �
����
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:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXIST7NG OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPEN[NGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
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 $_ j�, �� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
$ l'(, S-��d.� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the tota] job valuation
� 0 .0005 x Permit Valuation Minimum $5.00
$ �_ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to N1WCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ r Make checks pavable to: Citv of Fridlev Attac
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 ordinance d c es of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio o rmit 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 r quires review and approval of pla `
SIGNATURE OF APPLICANT � PRINT NAME �JG .SS DATE I� ��(�
APPROVAL INSPECTOR SIGNATU