P - 47912Building
Inspections
763-572-3604
763-502-4977 FAX
DATE , d:.,' Jdp
- �
SITE ADDRESS r
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I1-2011
YOUR E-MAIL ADDRESS
� c:e r ee � � ex- �r c c�;
❑ OWNER �CONTRACTOR
NAME: C, '
ADDRESS: ��
PHONE: �� �� "� 1 lp --� � p�'�Cj �
NAME: �,/l}C�Z,
STATE LICENSE � [� �3a�''��
ADDRESS:
H E
GLE FAMILY(NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ RAGE/SHED
❑ BASEMENT FINISH �OOF
❑ DECK ❑ SIDING
TYPE OF WORK: I ❑
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
Permit No
Received By:
������ � � i ' � STAT�-ftiZIP
CERT NUMBER EXP:
CITY
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
❑ SWIMMING POOL
HOME CONSTRUCTION ❑ ADDITION
fTENANCE/REPAIR ❑ REMODELING
LENGTH WIDTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
O DETACHED GARAGE
HEIGHT
TE ZIP.
FT
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
�
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT(FASCIA ADDIT[ONS. & PORCHES SUBMI7'
❑ Aluminum ❑ Trim REMOVED? ❑ YES O NO � Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construetion plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-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 $ . OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$ ��
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.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
Agreement necessary ( ) Non Necessary ( )
Make checlts 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 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 applicatio �r a permit-e d 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 or '�� e' e � i and approval of pl %�,�,� �J
SIGNATURE OF APPLICANT�,c� / JY PRINT NAME P i�� �--e.J DATE_ I01 `�' i�
APPROVAL INSPECTOR SIG]V�CYf E