P - 45810Building
Inspections
763-572-3604
763-502-4977 FAX
DATE U� � ��
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
Pi20PERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMF.NT
ROOFING
NUMBER OF SQUARES _
GARAGE5
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-i-2010
YOUR E-MAIL ADDRESS
❑ OWNER �,CONTRACTOR
NAME:
�
STATE LICENSE #
ADDRESS: �� �
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISI-T ❑ ROOF
❑ DECK �1' cmiN
Permit No.:
Received By:�r!U
Date ��: J �'N
TE `�_ZIP , ���`��
EXP DATE � I�� I p�
CITY_ ,LaM 0O'yIC1/�j STATE ,�N ZIP.
_ FAX_-I�3-..�� ` I3�J I
SIZE
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAIIVTENANCE/REPAIR ❑ REMODELING
i:_ _ '�P �I C� 4� r
LENGTH WIDTH
❑ HOUSE ONLY
_ ❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN TILE
❑ OTHER
FT
BASEMENT RFMODELIN SUBMIT�
1. Existing Floor Plan
Z. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
OSofiit ADDITIONS. & PORCH S BMIT•
O Trim 1. Site Plan/Survey showing the exisring structures
❑ Fascia and proposed project.
2
WINDOWS . Two sets ofconstruction plans
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS 3� Energy Calculations
OR FOR NEW OPEI�IINGS-DESCRIBE SIZE OF FOR WINDOWS — pROVIDE U-VALUE AND
OPENING CHANGES &
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
U ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL ,dOB V�LUATIQI!' $ �,� ��' � � OCCUPANCY TVPF.
Permit Fee
Plan Review
Fire Surcharge
Surchazge
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 Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$5.00 (5tate Licensed Residential Contractors)
$2100 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 eff9..
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 permit on site; that the work will be in accordance with the
approved plan in the case of all ork whi h requires review and approval of pl s.
SIGNATURE OF APPLICANT PRINT NAME 1 DATE l� a� �