P - 44922Building
Inspections
763-572-3604
763-502-4977 FAX
DATE {.�
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING D(
SIZE OF IMPROVEMENT
ROOFING "
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
� Vinyl
Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-]-20i 1
YOUR E-MAIL ADDRESS
O OWNER
ADDRESS: �`Z C� � �� L � C � �.e�-CITY
PHONE: ��p �j -�`] 1 j°1 CO 1
NAME:
�` C�eS � �. C—
STATE LICENSE i! '2C� Z_ LEAD CERT NUMBER
ADDRESS: �73��p � �pp � CC� �_CITY�
PHONE �9I 2- �j � Cp �( ��-( FAX ?C� �,—�i
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT F[NISH ❑ ROOF ❑ DRAIN TILE
❑ DECK Ji� SIDING ❑ OTHER
❑ SWIMMING POOL
NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
!V1 N\ c� (` C� � �
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GAIZAGE
❑ DETACHED GARAGE
HEIGHT
Permit No.
Received By:
�. ' �' � , i � � � �
i, ' _ � �
ATE�_ZiP,
ATE�I�,N ZIP���J�
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION 1NCLUDING DECKS,
❑Soffit ADDITIONS, & PORCHES SUBMiT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WtNDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPEAFINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENII�iG 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
$ $
$
$ �
$ .
$ -v
$
$
$
$
$ 1.3 .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+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined,by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: Citv of Fridlev
Attach
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a buiiding permit and I acknowleage that the information above is complete and accurate; that the work will be in
conformance with the ordinances and co f the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for e an l�s not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all w' r uires re ' rova of pl n. (�
SIGNATURE OF APPLICAN'f PRINT NAME�A �� `C� 1' O�/"� DATE .^"� /? ��6 I�_
APPROVAL INSPECTOR SIGNATURE