P - 35210Building BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE � ` � � � �
SITE ADDRESS � � J `
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:
Permit No.:
� • - - . : ' ���j��
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YOUR E-MAIL ADDRESS ��Ei L(') YI��,wC�C-}'Q�''j�Y , CQ�'YI
�� �'. N, E. Fr��)�.y -
� OWNE[2 �ONTRACTOR
NAME: ��YQ � IS
ADDRESS: SC}/li✓�� CITY
PHONE:_��o3 - � �l) ' I oS �
NAME: � �X )�l"S �t S/ 1 /'t S�!e.
S'fATE LICENSE #��`T3 S�� LEAD CERT NUM:
ADDRESS: ���IO� �j3 � � . �i. CITY_
PHONE ��D3 '3�5- bQ! � FAX !�3 -,,
INGLE�FAMILY SIZE
n
❑ BASEMENT FINISH
❑ DECK
CONSTRUCTION
�OOF
❑ SIDING
❑ SWIMM
❑ NEW HOME CONSTRUCTION ❑ ADDITION
.�MAINTENANCE/REPAIR ❑ REMODELING
❑ DRAIN TILE
❑ OTHER
STATE ZIP
/U %- !o%4/f)- �
O�£ 0✓ STATE�ZIP Srs3%�
� �'�s' � �
DESCRIBE WORK BEING DONE:� �} j- — d'Q( "�Q�' �"�{J �`Y1� (jU„�/WC.�G� L...
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT P S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES a� �I-IOUSE & GARAGE �. �xisting Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCT[ON INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXIST[NG OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCR[BE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, [NCLUDING THE COST OF LABOR AN� i�IATERIALS:
TOTAL JOB VALUATION $ � ��SING THE 1997 U.B.0 FEE SCEI OCCU ANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Contcol $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ (�� Make checks payable to: City of Fridlev Attach
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THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit d I ac wledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and co of e ity of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but o+ily an application r �t ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of a c res review and approval of plans ,�,�C /c
SIGNATURE OF APPLICANT AME �� � / L�' DATE � � /O ' ��
APPROVAL INSPECTOR SIGNA
PI.EASE NOTE: SEPARA7"E R . AR� RR()i TiRR1j FnR PT ;i TMXtrNt; RT .Rr"i12tr'��T �k1�ti'1� hA�f*i� �� i° '�tr .'� %=.i