P - 44957Building
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
SIZE OF IMPROVEMENT
R N
NUMBER OF SQUARES _
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2010 . �
YOUR E-MAIL ADDRESS
❑ OWNER �CONTRACTOR
STATE LICENSE
ADDRESS: �I i
PHONE /6`� 7'n�'S " .� Y � '
❑ SINGLE FAMILY/NEW CONSTRUCT'ION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH 0 ROOF
❑ DECK � SIDING
❑ SWIMIv1
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
f,7 HOUSE ONLY
❑ HOUSE & GARAGE
Permit No.: ��� b�i�t�0�-L.V
Received By:
Date Re��k�� � o '
CITY ( � STATEL
�
e �1 L
EXP DATE � ,
�U � /�/� CITY STA
T FAX �G"t v"t ,�
SIZE
STORIES
JSHED ❑ WINDOWS
❑ DRAIN TILE
O OTHER
NG POOL
❑ ADDITION
❑ REMODELING
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDllVG
�Vinyl ❑Soffit
❑ Aluminum ❑ Trim
O Other ❑ Fascia
WINDOWS
IN EXISTTNG OPENINGS �Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural membera to be usod
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets ofconstruction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
__(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surchazge
Surohazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �(/ 7 Z.� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ (p .001 times the total job valuation
$ d .0005 x Permit Valuation Minimum $.50
$ ' S'g $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ 7�� / Make checks aavabie to: City of Fridtey Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of Ciry of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case k w' r res review and approval of 1 s.
SIGNATURE OF APPLICANT PRINT NAME � ��' DATE I O
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