P - 45110Building
Inspections
763-572-3604
763-502-4977 FAX
DATE i • (
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
Sti33MIT' A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
O OWNER
NAME:�
ADDRESS:
YOUR E-MAIL ADDRESS
s�a-
STA7'E LICENSE # � �—f j} �
ADDRESS:
PHONE I — ��
�INGLE FAMILY TION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
� NEW HOME CONSTRUCTION
�MAINTENANCE/REPAIR
DESCWBE WORK BEING DONE:
ROOFING %� �
NUMBER OF SQUARES �J
GARAGES
PROPOSED SIZE.
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
O Other
CERT
FAX (o��� —I`
SIZE
STORIES
LJ GARAGE/SHED ❑ WINDOWS
�ROOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
Q ADDITION
❑ REMODELING
�[ • /
❑ HOUSE ONLY
�ITOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
O Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo LOCATTON OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
HEIGHT
�
Permit No.: �i�/� L%��
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ATL�J N.
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AT�i1�II ZIP,
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BASEMENT REMODELING SUBMIT:
l. Existing Floor 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 structures
and proposed project.
2. Two sets of'construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFAC7"URE STICKER ON WINDOW.
� TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BA5ED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE 5CHEDULE)
TOTAL JOB VALUATION $ � '�]—, .�(�Cr • °�_ _ 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
�����
—
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_ �
1
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See Back Page for Fee Schedule
65% of Building Permit Fee
.Ofll 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: City of Fridley 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 T understand this is not a
permit but only an appl' ' n for a permit and ork is not to start without a permit on sit ; that the work will be in accordance with the
approved plan in the cas f al rk w ch re u' es eview and approval of plan . ,I �� �)
SIGNATURE OF APPLICANT PRINT NAME � d DATE �i" • �
APPROVAL INSPECTOR SIGNAT E
PLEASE NOTE: SEP RATE PERMITS ARE REQUIRED Ff3R PLUMBING, ELECTRTCAL AND MECHANICAL WORK