P - 42374Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CIT� OF FRIDLEY
�-i-ZO�o
DATE !` Z i` �� YOUR E-MAIL ADDRESS
siTE fwDxESS S�G� zf 3 4— S'�7' It,% ,� �— f'� 1� l� y
THIS APPLICANT IS: I�OWNER ❑CONTRACTOR
PROPERTY OWNER/ I N
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
CI Aluminum
❑ Other
'�
� 3 �'�`'" `_
� —S� ���
Z�
CITY
STATE LICENSE # EXP DATE
ADDRESS: CITY
PHONE
L�NGLE FAMILY/NEW CONSTRUCTION
[� TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
❑ GARAGE/SHED
❑ ROOF
� SIDING
❑ SWIMMING POOL
FAX
SIZE
STORIES
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
,. +L' h� �G� C. `P_ �� Y O Y�� i�r � 1 vL c.� O
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS es ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS- ESCRIBE SIZE OF
OPENING CHANGES &
ALLED
NUMBER OF
❑ DRAIN TILE
❑ OTHER
HEIGHT
Permit No.:
Received By: i� V
Date��t `�: J � G._ � �. � � �
'A'
ATE ZIP
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of consWction 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 $� �:A �� 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
$
$
$ ��
$
$
$
$
$
$ .
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)
$2100 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation P1an 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 VAi,ID 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 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 all rk w h requires review and approval of plans.j�
SIGNATURE OF APPLICANT �-��,`j \ f��, PRINT NAME � � i� "t'j ►1 S�� t�CS DATE �— Z�— I�