P - 39352Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS _
THIS APPLICANT IS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRID,LEY
EFFECTIVE I-i-20] 1
YOUR E-MA1L ADDRESS
❑ OWNER ❑CONTRACTOR
PROPERTY OWIYER/ NAME:� A V� 1" G O� Q� T%�- ,Z-.'1� `R-`-.� � N
TENANT ,e,DDRESS:J�� � � �i�h -� r %1 �- CITY
PHONE_�I2-"' �j `z3•`� — �7%�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
Permit No.:
Received By: �
Date � ,.� p -
ATE ZIP
NAME: �� I.� � �� '%_ � lJ G- � �/ �j*JL
STATE LICENSE #� ���3 %%% Z LEAD CERT NUMBER
ADDRESS: �7 ��23 `"' 2�I ��'i hI C1TY STATE ZIP
PHONE %�p J� I � J S^ �'l %� 2 FAX ��� L/ 6 h' -- �/ /'7_-)
�SINGLE FAMILY/NEW CONSTRUCTION S[ZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑�DITION Q GARAGE/SHED � WINDOWS
❑ BASEMENT FINiSH �,ROOF ❑ DRAfN TILE
❑ DECK ❑ SIDiNG ❑ OTHER
❑ SWIMMfNG POOL
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
ROOFING '`
NUMBER OF SQUARES 2 �
GARAGES •
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
❑ Other
GTH _ _ WIDTH _______ HEfGHT
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION RJCLUDTNG DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim I. Site Plan/Survey showing the existing structures
and proposed project.
❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
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)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �1'I�ZS
$
$ �
$
$
$
$
$
$
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$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach Sti
THIS IS AN APPLI'CATION 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 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 1 work which requires revieW and approval of plans. �_"�
SIGNATURE OF APPLICANT PRINT NAME /S %��/���u ��� DATE G%"" �"� � I
APPROVAL INSPECTOR SIGNA