P - 45694Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 1�� - a � ' � �
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
SITE ADDRESS _ ��"( � �.�/ S �
THIS APPLICANT IS
PROPERTY OWNERJ
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBB WORK BEING
SIZE OF IMPROVEMENT
❑ OWNER
NAME:
YOUR E-MAIL ADDRESS
�
Permit No.: ��
Received By:
� � ����
ADDRESS:_ �Ci� �ll-1 (S/ CITY �� ^�,�I�u� STATE��,IP
PHONE: �b S� "' �% �� � l ���
NAME:y��"1%�'Lv'S%G. S �
STATE LICENSE #�G`�lI%� LEAD CERT NLIMBER ,��'T�"�U���j= �
ADDRESS: � C� P C- / CITY�JAAI� �'`����. STATE�IP S� 3( �
PHONE G� � �l i
�SINGLE F ILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCT[ON
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCElREPAiR
ROOFING
NUMBER OF SQUARES �`
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ GARAGE/SHED
�iooF
❑ SIDING
O SWIMMING POOI.
_ _LENGTH
❑ HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
W INDOW S
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
ADDITION
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRA[N TILE
❑ OTHER
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION �NCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Pian/Survey shawing 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.
' TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VAI.,UATION $ SZ v ' 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
$ �`�� z5
$
� I `1
$ ►�0
$ �bi�
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.00] 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 Stipulations
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 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 a�ll w! �ch res review and approval of�s. �—
SIGNATURE OF APPLICAN� ��� PRINT NAMC�'G'c�y pC�'` ,iL�` DATE l�r`'? � It
APPROVAL [NSPECTOR SIGN��� , --T