P - 39350Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-201I
Permit No.:
Received By:
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DATE � ! � � `Z D �� YOUR E-MA1L ADDRESS �:S�Q f1'�y � ��,� "' C/(% `7
sITE ADDxESS 5'�"3 � L^ 5—�'� S�Y�.,. � .f�G �r�'� �^ �
THIS APPLICANT IS: ❑ OWNER �]CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
1NSURANCE
PROPERTY TYPE
PERMIT TYPE
ADDRESS: � Z�$� aiPk r�[ sfi, /YiAl C[TY �AUd'' I��/'� S STATE�%i/ZIP S�j`'l�
PHONE:�CU`i " 7C'�7 –�� I �'
NAME:_ �1 P %l 7 r� ��Y �
STATE LICENSE #�%�j �i Z'�7 Ga � LEAD CERT NUMBER
ADDRESS:_ �( �I6 �Htlt�� 1i/1= /Jj. CTTY�r' C"�l.vY STATE'�yZIP �.S LL
PHONE I� �2 ^�( y' S�% b� FAX
�INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
� ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAfN TILE
❑ DECK � SIDRJG ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELiNG
DESCRIBE WORK BEING
SIZE OF [MPROVEMENT_
ROOFING
NUMBER OF SQUARES _l� _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
O Other
TH ______ WIDTH _________ HEIGHT
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
FT
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDTNG DECKS,
❑Soffit ADDITIONS, & PORCHES SUBMIT:
❑ Trim �• 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 WtNDOWS 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 NUMB6R OF WMDOWS
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 Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
�Q (�'� d�(� 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
lations
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 without a permit on site; that the work will be in accordance with the
approved plan in the case o����k wh' ires review and approval of pl � � � l6 / 7�6 %
SIGNATURE OF APPLICANT PRINT NAME �� � ►'/�� I DATE
APPROVAL iNSPECTOR SIGN�TURE —�