P - 42122Building
Inspections
763-572-3604
763-502-4977 FAX
DAT]
SITE
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:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
YOUR E-MAIL ADDRESS
�% � �r.�� I.� i�'11V
�CONTRACTOR �—
Permit No.:
Received By:
..:, .` �� _ � .
tvaNte: c w�,
ADDRESS:�o � �� :GuJ e f f E CfTY � � STATE�ZIP s�z�3�
PHONE: ��3' ��1G ' ��i�
NAME:_ w.c..v. W� e�"'�
STATE LICENSE # LEAD CERT NUMBER
ADDRESS:��3�" �%h,�%Ci��'� � CITY r� STAT��ZIP
PHONE �` 'J�71 �_ I � 3_3 FAX
�1 SINGLE FAMILY/NEW CONSTRUCTION
O TWO FAMILYMEW CONSTRUCTION
� BASEMENT FINISH
❑ DECK
❑ GARAGE/SHED
,� ROOF
❑ SIDING
❑ SWIMMING POOL
SIZE
STORTES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: C� CO��
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminnm
❑ Qther
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffi[
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF \
F"T
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of consuuction 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
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 5�04� OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ a�
$
$
$
$
$
$
$
$ ,
TERIALS:
See $ack 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 payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR 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 applic i r 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 ich requires review and approval of �}lans. C k���� `/DATE �D// /
SIGNATURE OF APPLICANT PRINT NAMEV �V�Ct \�d �. twis J�J f(
APPROVAL INSPECTOR SIGNATURE