P - 46260Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
L ADDRESS
❑ OWNER ❑CONTRACTOR
a�('� St�(IQ..
Permit No.: "� t�" �� U�''7
Received By: �
Date Rec'd:
R�C�-�i� � , �
ADDRESS:(p�SS C�lJa�Shl^C��1 `r'j�'�I�' CITY �'�\G`�'-� STATE�_�IP S5y 3E
PHONE: � Ge �i "' S^% i" �'! � Co r�—
NAME:
STATE LICENSE # LEAD CERT NUMBER
ADDRESS:
PHONE
�INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT EINISH
❑ DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING ,."�
NUMBER OF SQUARES 3 �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENIIJG CHANGES &
TYPE OF WiNDOW TO BE INSTALLED
FAX
SIZE
STORIES
❑ GARAGE/SHED ❑ WINDOWS
8`�200F ❑ DRAIN T1LE
O SIDING ❑ OTHER
O SWIMMING POOL
❑� DDITION
si7 REMODELING
a t�� ('sz f� (�t crL �� 8
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
� DETACHED GARAGE
❑So�t
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
ATE ZIP
FT 3 v
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plaq
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION RJCLUDiNG DECKS,
ADDITIONS & PORCHES SUBMIT�
1. Site PIanlSurvey showing the existing stnrctures
and proposetl project.
2. Two sets of construction plans
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)
TOTAL JOB VALUATION $" 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
$-�t I_� . 7 5
$
$ r—
$
$
$
$
$
$
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)
$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 Fridley
Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a building permit and 1 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 o�k ich r ires review and approval of pl �
SIGNATURE OF APPLICAN � C��,%� PRINT NAME ��J ,.�"�. DATE �� �/ II
APPROVAL INSPECTOR SIGNATURE � '