P - 44987Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I I ' � — I
SITE ADDRESS ��
THIS APPLICANT IS:
PROPERTY OWNE� T
TENANT I
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
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
YOUR E-MAIL ADDRESS
� �
❑ OWNER Ji�CONTRACTOR
NAME:
ADDRESS�: y I o (%
PHONE; /!Q_ � s 7� ^ b S �
NAME:
STATE LICENSE #
ADDRESS:
PHONE
SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ NEW HOME CONSTRUCTION ❑ ADDITION
.�MAINTENANCE/REPAIR ❑ REMODE
E: �
LENGTH WII
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
EXP D �
CITY�
FAX
SIZE
❑ DRAIN TILE
❑ OTHER .
�-y �a3 �3
Permit No..o��' �
Received By �
Dat��e��ld�.��' � �
w
TE I�l/v,
FT
BASEMENT REMODELING SUBMIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS_ & PORCHES SUBMIT:
❑ Vinyl ❑Soffit 1. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim and proposed project.
❑ Other ❑ Fascia
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �(I'es ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED � MBER OF WINDOWS �
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 Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
e
$ �( (�L`J 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)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ �}+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � 0 7► Make checks payable to: City of Fridley Attac
THIS IS AN APPLICATION FOR A PERMIT-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 ordin d codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applic on fo a permit d ork i not to start without a pe it on site; that the work will be in accordance with the
approved plan in the case f all o k whi q e e w an approval of plans. /
SIGNATURE OF APPLICAN N A DATE /��' � /D
APPROVAL INSPECTOR SI �