P - 42202Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit
Received By:
Date Rec'd:
DATE_ � ' � ' � I YOUR E-MA[L ADDRESS � � %� % C�-�A/2 �i �� � C /`�/� '�L = � c� ./—I
SITE ADDRESS S � D � 3 rc D S �/�°4 `� '� N� ( /l � �(i�-+�-( /`T � �� � � ,� %
THIS APPLICANT [S: �OWNER ❑CONTRACTOR
PROPERTY OWNER/ N;�E: �,�n y� f���ZG����°
TENANT ,yDDRESS _�� �° � �'%` CITY
PHONE: � Y � '" 5 � � — /C � �
!"�AI�TTT � !`�TAT
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
`�� �Y `� STA
STATE LICENSE #t LEAD CERT NUMBER
ADDRESS: CITY STATE ZIP
PHONE Fax
PROPERTY TYPE I I�I SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
�' MAINTENANCE/REPAIR
❑ GARAGE/SHED
� ROOF
❑ SIDING
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
DESCRIBE WORK BEING DONE: /�1-� n�A �-� Sit �:� %�-• S� N e w 5 K([_• `G S%�S'
_�
SIZE OF
ROOFING
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
IDIN
❑ Vinyl
O Alutninum
O Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE iNSTALLED
fOT
� HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
❑ DRAIN TILE
❑ OTHER
HEIGHT
FT
BASEMENT REMODE�.iNG SUBMIT•
1. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDtNG DECKS,
ADDITIONS. & PORCHES SUBMIT•
1. Site Plan/Survey showing the existing structures
and proposed project
2. Two seu 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)
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
$
w
�������/
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$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: Citv of Fridlev
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 I understand this is not a
permit but only an application for rmit d 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 w' quires review and approval of plaf�s.
SIGNATUREOFAPPLICANT PRINTNAME (SAR����J�ii�-o,�,�,�ATE �"'��'— I /
APPROVAL INSPECTOR SIGNATURE