P - 43634Building BUILDING
Inspections RESIDENTIAL APPLICATION
�6�-s�2-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 7-1-2010
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DATE �. l !. i.-� \/ .�-� S f- � �Ld /� v YOUR E-MAIL ADDRESS _ C ��l�'`�!'�'�C� � ✓�� .
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SITE ADDRESS � �� � �� / 'L, �7 l.( l�"C'�i l�? l,l C'.:.' J IiC�� t°=�'. /cr�C:k' / :�-_. , /r /?�C/ r;s
THIS APPLICANT IS: f� OWNER ❑CONTRACTOR
�
PROPERTY OWNER/ NAME:_
TENANT ,q�DRESS:
PHONE: L
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
STATE LICENSE #
CITY
EXP DATE
Permit No.:c�'�l� � � � �
Received By:
Date��: ���L 2i 2�
/�� � � /°���
.� .-.
STATF�ZIP � ..� v
ADDRESS: CITY STATE ZII'
PI-�ONE FAX
� SINGLE FAMILY/NEW CONSTRUCTION SIZE /D S�U:IS
17�4'WO FAMILY/NEW CONSTRUC ION STORIES r!
❑ ADDITION GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
O MAINTENANCE/REPAIR ❑ REMODELING
('�i�„�'��rurfja�� � iZ'x /�' .�'�vzr�'� v�✓v r ,
- -- - - �' � � --- , -, i
SIDING
❑ Vinyl
� Aluminum .
0 Other
wnvnows
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
� j � (�
en xr
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing ff►e existing sirucUares
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $_ ��'� d� OCCUPANCY TYPE
"_
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
' Sewer Main Charge
II Total Due
$ __''l� [+2�5 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)
$ $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 ( )
$ D, S Make checks navabte to: Citv of Fridlev Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge that the informarion 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 ap ' ion 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 ase of si� j� k which re ' es re i„ew and approval of plan .�� ., . �/Z���Q/ �
SIGNATURE OF APPLIC T PRINT NAME�D ,�/ � Lu.k��' DATE
APPROVAL INSPECTOR SI