P - 47784Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
�
DATE� �'y'—I � YOUR E-MAIL ADDRESS
SITE ADDRESS ��( ,�� � � � � � ' � ..
THIS APPLICANT IS: ❑ OWNER mL�ONTRa�Tnu
PROPERTY OWNER/
TENANT
ADDRESS: CITY
PHONE:
Permit No.:
Received By:
��,' �� ' �
ATE ZIP
CONTRACTOR NAME:�=��-�-��� .�,.,, ��3��
SUBMIT A COPY OF STATE LICENSE #�CY�,�j( �Z. LEAD CERT NUMBER
YOUR STATE LICENSE �� ���,� - _ �
AND CERTIFICATE OF ADDRESS: •7� j,�,( t��,�� �,,-1 �.
INSURANCE _ � �� CITY �=- ;;QC�'-�„� STATF,��'1ZIp�� _
PHONE - . '�.�C'U ' �c� S�i' FAX
PROPERTY TYPE �NGLE FAMILY/NEW CONSTRUCTION SIZE
❑ WO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑.j�YpOF ❑ DRAIN TILE
❑ DECK Q�SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ I�EW HOME CONSTRUCTION ❑ ADDITION
INTENANCE/REPAIR ❑ REMODELINC
DESCRIBE WORK BEING DONE: P�- -���_
SIZE OF IMPROVEMENT LENGTH WIDTH
HEIGHT S FT
ROOFING /� ❑ HOUSE ONLY
NUMBER OF SQUARES /�• ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT•
GARAGES ❑ ATTACHED GARAGE �• Existing Floor Plan
PROPOSED SIZE: ❑ DETACHED GARAGE 2• Proposed floor plan
PROPOSED HEICHT: 3. List of structural members to be used
SIDING
O Vinyl
❑ Aluminum
❑ Other
❑Soffit \ �
❑ Trim �,\��
❑ Fascia
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS 8c PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
WINDOWS z. Two sets of construction plans
IN EXISTWG OPENINGS ❑Yes ❑No LOCAT[ON OF WINDOWS 3. Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROVIDE U-VALUE AND
OPENING CHANGES & MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF W[NDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TVPF
' Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ � �e
_$
$
$
$
$
$
$
$ .o
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 pa able to: City of Fridley 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
pernut 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 1 0� whi h equires review and approval of plaps
SIGNATURE OF APPLICANT • � •' PRINT NAME ���� � - � � �, ._ �
APPROVAL INSPECTOR SIGNA U E " DATE ����_
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