P - 47780Building
Inspections
763-572-3604
763-502-4977 FAX
,� DATE ' l —
SITE ADDRESS
THIS APPLICANT IS:
ricvr�KlY UWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
❑ OWNER
ADDRESS:
PHONE: �
CONTRACTOR N,�E:
SUBMIT A COPY OF v'4�
YOUR STATE LICENSE STATE LICENSE #
AND CERTIFICATE OF ADDRESS:��U
INSURANCE pun�.r� 1. � .
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVFMF�tT
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
_ YOUR E-MAIL ADDRESS
�NTRACTOR
�
'���k- CITY �
� '^- S ) 1 N G.
���� LEAD CERT
FAX � �'
INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �ROOF 0 WINDOWS
❑ DECK � DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITfON
�vIAINT�ANCE/R�E,�PAIR ❑ REMODELING
r�
ROOFING
NUMBER OF SQUARES _p�.�_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF wnvnnu�c
Permit No.
. _ �1�
_� � _
�. � - �
.
1 � " �
• �
ATE � ZIP
STA
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BASEMENT REMODELING SUBMIT:
L Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDiNG 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.
"LL r�,�,J Ax�; �A��:ll ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $ �USI�N�G THE 1997 U.B.0 FEE SCHEDULE)
Yermrt Fee
� ��� " OCCUPANCY Tvv�
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sevver Main Charge
Total Due
$
$
$
$
$
$
$
$
$
$ [� 1 �
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)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6$= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to Cit of Fridley Attach St�pulat�ons
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 a codes f e City of Fridley and with the Minnesota Construc 'on Codes; that I understand this is not a
permit but only an application fo per i an work is not to start without a p it on site; th the work will be in accordance with the
approved plan in the case of al] w c e ires r' w and approval of plan .
SIGNATURE OF APPLICANT / `/ �`
APPROVAL INSPECTOR SIGNA RE PRINT NAME N� O DATE (�
� �
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