P - 43050Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
DATE %d h�-',T �( YOUR E-MAIL ADDI2ESS �/v�J�u"��
SITE ADDRESS '7�� �%( v� �2 �`< �L
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
TY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BE1NG
SIZE OF IMPROVEMENT
❑ OWNER '�9PITRACTOR
ADDRESS: CITY
PHONE:
NAME:_�_�//�C C—Ph�+ STi2 u c 7`/ D N
STATE LICENSE # 40 i�o �
ADDRESS: 0�0 y OIQGG�JD�-i G� ,Q
PHONE " �t� ' S� — �Z�S�7
Permit No2o � � �
Received By:
Date Rec'd: '
i'�i`/t�• C�Q.7l
STATE ZIP
CERT NUMBER
CITY C� I�''�'�L�^� STATFI�/�ZIPS��
x 7/03 — -s�� -a o, v
�6iNGLE FAMILYMEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORtES
0 ADDITION ❑ GARAGE/SHED ❑ W[NDOWS
❑ BASEMENT FINISH �OF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMMG POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
O MAINTENANCE/REPAIR ❑ REMODELING
ROOFING 2 �
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
0 Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
�'
o� ���se 4 6�R.¢6�
❑ HOUSE ONLY
�OUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION tNCLUDiNG 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
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
( SING THE 1997 U.B.0 FEE SCHEDULE)
T'OTAL JOB VALUATION $�I �'�. OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Cutb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �17, 2� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ 3.( .001 times the total job valuation
$ ( . (Q .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 pavable to: Citv of Fridlev Attach
THIS [S AN APPL[CATION FOR A PERMIT-NOT VAL[D UNTtL 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 applicat' or 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 cas of all o k whi uir view and approval of pl s. �
SIGNATUREOFAPPLICAN " PR TNAME_�dDN�Gr/��SG�W�t'LDATE �d �C� //
APPROVAL INSPECTOR SIGN URE /.1i iT
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