P - 39351Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
DATE
SITE ADDRESS
TH[S APPLICANT IS: ❑ OWNER
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
SIZE OF [MPROVEMENT
ROOFING
NUMBER OF SQUARES� I�
GARAGES
PROPOSED SIZE:
PROPOSED H6IGHT:
SIDING
❑ Vinyl
O Aluminum
❑ Other
NAME: .�----�
STATE LICENSE #
ADbRESS: � 3
YOUR E-MAIL ADDRESS
❑CONTRACTOR
/2- �'3�,-
Permit No.:
Received By: ��`'�'�
Dat��:��� � �J ��l��
STA
CERT NUMBER
CiTY C(�/Sija q STATF�'i�N ZIP ���+'L�
FAX
�INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �]�F ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑� DITION
❑ MAINTENANCE/REPAIR [�EMODELING
�
LENGTH
[7 HQ'�JSE ONLY
�SE & GARAGE
TTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS �Yes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
HEIGHT
FT �/' �
BASEMENT REMODELING SUBMIT:
L Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION RJCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of conswction plans
3. Energy Calculations
FOR WINDOWS — PROViDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WMDOW 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)
COTAL 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
$
$ C7
$
$
$
$
$
$
$
$ lllln �
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.00OS 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 payable to: Ci� of Fridley _ Attach
THIS IS AN APPLICATION F�R A PERMIT-NOT VAL[D 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 application for a permit 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 all� k q' es review and approval of plan�.. / / �
SIGNATUREOFAPPLICANT E��9='"-" � PRINTNAME �� I�^°v5ov� DATE OT/i� �, /�
APPROVAL INSPECTOR SIGNATURE