P - 46485Building BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-I-201I
DATE �� /i�" �� YOUR E-MAIL ADDRESS f/� ��/��4�/E
SITE ADDRESS _ �6 �,7 � �%G'�� �� �
THIS APPLICANT IS: ❑ OWNER ,��ONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
Permit No. ���� ���� �
Received By: •
������ p ,�:
./Cir �
NAME: /�,(/S�1 4L G!/L/^�,/�i�
ADDRESS: �ic� ) .�� � ��Z - CITY ����� � E/ STAT60�'L��IP�
PHONE: r� r.z ` ��� I� rp �--.
NAME: QG� �C�' /±?/��f'�"' �/�/�i f�`/�' �.. r
STATE LICENSE # �/,�%. ? / � � LEAD CERT NUMBER
ADDRESS: J��j ���•�'t /J�/—/l— �; CITY S%�.�"ljLl���►L STAT�'LIP �i � 7
PHONE 76.�� �7 �' O�/�� Fp}t ��
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH C�1 ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR L+3 REMODELING
:: "7��,/!/i �`af%� � /1 � �2fat�%
ROOFING , (�
' NUMBER OF SQUARES C7
I GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WtNDOWS
NUMBER OF WINDOWS
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of struc±ural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing 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.
ALL N'L�5 AK�; BASEU UN VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ ��.� � See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ �zjj�_ .001 times the total job valuation
Surcharge $ � Z a .0005 x Permit Valuation Minimum $5.00
License Surcharge $ fj�(� $5.00 (State Licensed Residential Contractors)
SAC Chazge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
I Erosion Control $ $450 Conservation Plan Review
', Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ — 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 I understand this is not a
permit but only an application for a permit and work is not to start withou�._permit on site; that the work will be in accordance with the
approved plan in the case of all w k which require review and �f plans. /� L�
SIGNATURE OF APPLICANT ��ij� PRINT NAME �Q�l�i� �� DATE �/ // `��
APPROVAL INSPECTOR SIGNAT RE