P - 47296Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � (
SITE ADDRESS Q
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 11-201 ]
YOUR E-MAIL ADDRESS
V ef vIPUi tP �(�f/'P.L/�
O OWNER CONTRACTOR
NAME:
ADDRESS: �O , ' ue.� ' � ��rr�
PHONE: — a
NAME:
STATE LICENSE # Q Q T ('�
ADDRESS: �
PHONE —r
� SINGLE FAMILY/[�IEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
Permit No.: �.� � i� �(� �j�
Received By:
Date R�''�� � � U � �
� CiTY
�
�
�LEAD CERT NUMBER /�/
�_CITY
FAX �- � —
SIZE
❑ BASEMENT FINISH v, L�U11LL
❑ DECK I�QOF
❑ SIDING
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ SWIMMIO ADDOITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: e �p �� !
SIZE OF IMPROVEMENT LENGTH
WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES � �30USE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: O DETACHED GARAGE
PROPOSED HEIGHT:
❑ DRAIN TILE
❑ OTHER
�A7�E��IP
EXP:
TATf
ncivti i SQ FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS & PORCHES SUBMIT
O Aluminum ❑ Trim REMOVED? ❑ YES � NO � Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
WINDOWS 2. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS 3 Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROViDE U-VALUE AND
OPENING CHANGES & MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDQWS
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 TYPF
Permit Fee - • -
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$ S
$
$
$
$
$
$ !� ,
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 ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pa able to: Ci of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL 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 ' nd work is not to start without a permit on site; that the work will be in accordanc with the
approved plan in the case of requires review and approval of p ns.
SIGNATURE OF APPLIC PRINT NAME (J �j r
APPROVAL INSPECTOR SIGNATURE f C SDATE
Y,. �,�.,� :;�,.:wv.:,.. �� ..,,: . .,, ,. �� , ... _. _
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