P - 42126Building
Inspections
763-572-3604
763-502-4977 FAX
DATE `I � .7U �
SITE ADDRESS –����
THIS APPLICANT IS:
PROPERTY OWNE� J
TENANT I
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PdtOPERT'Y TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2011
❑ OWNER
� � %V •r�
STATE LICENSE # LEAD CERT NUM�
ADDRESS: CITY
PHONE — FAX
�LNGI:E FAA4ILY/NEW COrISTRUCTION SIZF,
TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
d'(MAINTENANCE/REPAIR � REMODELING
���7�
Permit No.:2
� .:
' 1 M
..-�- �
SIZE OF IMPROVEMENT V LENGTH WIDTH HEIGHT S FT
ROOFING � ❑ HOUSE ONLY BpSFMFNT REMODELING SUBMIT•
NUMBER OF SQUARES �'fiOUSE & GARAGE L Existing FloorPlan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED STZE: ❑ DETACHED.GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
IDIN ADDTTIONS & 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 ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS – PROVIDE U-VALUE AND
I OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
I OPENING CHANGES &
I TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEE5 ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
���SII� THE 1997 U.B.0 FEE SCH �CCiJPANCY � TYPE
TOTAL JOB ��ALUATJON S IJ�J
Permit fiee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ � f �� GS See Back Page for Fee Schedule
$ 65%0 of Building Permit Fee
$ 3 .001 times the total job valuation
$ .0005 x Permit Valuation Minirnum $5.00
$ C�(�(� $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 Fridle_y Attach Stipulatio
�- - -
THTS 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 ordi es and codes o e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an appli tion or a permit or ' not to start without a ermit on ite; that the work will be in accordance with the
approved plan in the case of al ork ' h ' s w and approval of pl � 1/ (�, ��� —/ /
SIGNATURE OF APPLICAN RINT NAME ti I F�• DATE ��
APPROVAL INSPECTOR SIG RE
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