P - 35777Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ��� '�� �
SITE ADDRESS S�Y / L�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-I-2011
YOUR E-MAIL ADDRESS 9r �4 �
❑ OWNER
Permit No.:
Received By: (,"�'
Date R�c�: � L 2 A � d�
.
/:
NAME: (� C
STATE LICENSE #
PHONE if'G>!S —
PROPERTY TYPE I�INGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTI4N
PERMIT TYPE � �DITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF [MPROVEMENT
❑ GARAGE/SHED
�;ROOF
O SIDING
❑ SW[MMING PO(
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAIt�I�'ENANCFA/REPAIR ❑ REMODEL
_ l�.� n ts� _. r— C ./� .AA _
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
lN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENIIVG CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
,D CERT NUMBER
CiTY STA��ZIP�
FAX 3`---5�'�fL �Z�c�s
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
HEIGHT
F'f
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTtON INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction 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 $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Ci�arge
Total Due
���
� i
See Back Page for Fee Schedu(e
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 Stipulations
THIS [S AN APPLICATION FOR A PERM[T-NOT VALID 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 ordinanc an codes of C' r ley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applica ' n pe ' wo is t to start without a permit on site; tha the work will be in accordance with the
approved plan in the case f k whic requi e approval of pla /
SIGNATURE OF APPLICANT � PRINT NAME �� /J bijATE �_���'— l/
APPROVAL INSPECTOR SI RE