P - 35261Building BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTTVE i-1-2010
DATE ���►!~l� YOURE_-/MAILADDRESS �I=�D�//OMGf
SITE ADDRESS J s[�i " J !� �.��Q��ii� _ S.i 7Z l
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
❑ OWNER �1
NAME:_ %"��
ADDRESS:_ �"wy a�—
PHONE:��
NAME: �' i�
STATE LICENSE #f Z
�
EXP DATE
ADDRESS: p /O�I'V /v fC CITY
PHONE T " 7 � FAX �"
SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�f MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
NUMB�ER OF SQUARES �R �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
❑ HOUSE ONLY
� HOUSE & GARAGE
❑ ATTACHED GARAGE
'� DETACHED GARAGE
Permit No.:
Received By: �'�l�i
D���'d�� 4! � 1 ����
A'I'�� ZIP,
BASEMENT REMODEL(NG SUBMIT:
1. Existing Floor Plan
2., Proposed floor plan
3. List of struct�ral members to be used
SIDING FOR NEW CONSTRUCTION INCLUDTNG DECKS,
O Virryl ❑Soffit ADDITIONS_ & PORCHFS SUBMIT.
❑ Aluminum ❑ Trim 1• Site Plan/Survey showing the existing structures
0 Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTTNG OPENINGS OYes ONo LOCATION OF WINDOWS FOR WINDOWS – PROVtDE�ll-VALUE AND
OR FOR NEW OPENINGS-AESCRIBE SIZE OF MANUFACNRE STICKER ON WINDOW.
OPENING CHANGES & �
TXPE 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 $� p�'J►b �� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Etosion Control
Park Fee
Sewer Main Charge
Total Due
S �"�, L5 � See Back Pag,e for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ � �U�.? $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( �
$ Make checks aavable to: Ciri of Fridlev Attacl
THIS IS AN APPLICATION FOR A PERMIT-NO? VALID L1NTTL 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 Gity o�ridley 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 o�y3rc�k vhich uires vie � d approval of plans.
SIGNATURE OF APPLICANT � ���4C�'� PRINT NAME l u�+► �/��"'�i Y'{�� � DATE �"� � i'�' !�