P - 44984Building
Inspections
763-572-3604
763-502-4977 FAX
DATE `J / /j
SITE ADDRESS _�
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:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED S[ZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS �
E�1 U �� !R �C„ 11�%/e .. /V , ��G► . n t� �
OWNER ❑CONTRACTOR
NAME:
STATE LICENSE tl
LEAD CERT NUMBER
Permit No.:
Received By:
��
ATE �''1 �ll ZIP
ADDRESS: CITY STATE ZIP
PHONE p�
SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ BASEMENT FINISH
� DECK
❑ NEW HOME CONSTRUCTION
� MAINTENANCE/REPAIR
W WDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ ROOF � ❑ DRA[N TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
s-
O HOUSE ONLY
� HOUSE & G,4RAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
BASEMENT REMODELING SUBIvIIT:
1. Existing Fioor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT•
`� 1. Site Plan/Survey showing the existing sWctures
� 7' \ and proposed project.
''J�•.��" 2. Two seu of construction plans
f 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)
COTAL JOB VALUATION $�L.�Dl� �— OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Fermit 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$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: Citv of Fridlev Attach
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 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 permit and work is not to start without a-pe=�it on site; that the work will be in accordance with the
approved plan in the case of rk hi q i evi and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME DATE
APPROVAL INSPECTOR SIGNA R