P - 35260Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� t �1 I.C,
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20ll
❑ OWNER
STATE
0
YOUR E-MAIL ADDRESS
PROPERTY TYPE + �SINGLE FAMILY/NEW CONSTRUCTION
I ❑ TWO FAMII,Y/NEW CONSTRUCTION
PERMIT TYPE
O BASEMENT FINISH 6�ROOF
❑ DECK ❑ SIDING
Permit Na�-� ���� S J�
�-
Received By:
�����d:_ � 1 ��11
�uaE�s�tti��Zr.
� /iL �� �
� � i f 1
• � ' �� ' �� � �/
� c ✓II►Gi%f�ri
.
�
. •�
■ �•
■ � • � �
a • 1.��:
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDIT'ION
MAINTENANCE/REPAIR ❑ REMODII.ING
DESCRIBE WORK BEING DONE: � �
SIZE OF IMPROVIItitENT LENGTH WIDTH
O HOUSE ONLY
NRU�MBER OF SQUARES _�� �OUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: 0 DETACHED GARAGE
PROP05ED HE[GHT:
TE�ZIP
I�
BASEMF�IT REMODE[.ING SUBMIT:
1. Facisting Floor Plan
2. Proposed 800r plffi
3. List of structural membe.�s to be used
�IDING FOR NEW CONSTRUC'PION INCLUDING DECKS,
❑ Vinyl p��t ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim
1. Site PladSurvey showing tt�e existing structures
❑ Other ❑ Favcia
azed proposed projecY.
2. Two sets of conctr�tion plans
WIlVDOWS 3. Fnergy Calctilations
IN EX[STING OPENINGS DYes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACNRE S77CKER ON WINDOW.
OPENING CHANGES Bc
TYPE OF WINDOW TO BE INSTALLID NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
`, (USING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION
Permit Fee
Ptan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ (�: L� See Back Page for Fee Schedule
$ 65% of Building Pemut F�
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ SS.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 Engincering
$ Agreement necessary ( ) Non Ne,cessary ( )
S �� 4'1 Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a building permit and I aclmowledge 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�rmit and work is not to start without a permit on site; that the work will be in acxordance with the
approved plan in the case o �1! workv�hich requires review and approval of pl /�
SIGNATURE OF APPLICANT �G.�-�,�6ld 11� PRIN't' NAME P�t� il�� � n t.� DATE �(�LC.I t 1 � r
APPROVAL IIJSPECTOR SIGNATURE ��
-:i11�IaF.`I��C�➢r�i.y�IJ\;L•1fYDl,SI:i�olYi.`�,:i�:7�Ci]i11N91i7�Cll;���Hel:ll.(t��1�5�iiY.atM•_\iI\.{�7��i��:/:�:l��ii��#Ili�:i'�