P - 46805Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
__ EFFECTIVE 11-20] 1
Permit No.:�'
�
Received By:
Date �
DATE � I ' � �' � � YOUR E-MAIL ADDRESS �OT �D LT��/11 � p� Q MQ� ( • �� M
SITE ADDRESS 5G y9 S�L 'S�' /✓ �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
suBMiT A coPY or
YQUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
❑ OWNER �ONTRACTOR
aDD�ss: 3Gy9 S f''� sf �✓E c�TY L.��
PHONE: lp ��' Y 8�e - e� �Gj �
STATE LICENSE #
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH [�'ROOF
❑ DECK ❑ SIDINU
STATE�►.�Zipssy3a
EAD CERT NUMBER EXP:
CITY,�—STATE /h i✓ZIPss3?S
FAX %G 3 -�,i� F' - 30,3'�
SIZE
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
LI SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTKUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: � I' p� A� h0� Q,r��i �q qr4 9�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT
NUMBER OF SQUARES .� � �EiOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HfiIGHT:
SIDING FOR NEW CONSTRUCTION INC�DING DBCKS,
❑ Vinyl ❑Soffit SIDINGlSOFFTT/FASCIA ADDITIONS. & PORCHES SUBMIT
❑ Aluminum � Trim REMOVED? ❑ YES ❑ NO � Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS QYes ONo LOCATION OF WINDOWS FOR WINDOWS – PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE 1NSTALLED NUMBER OF WINDOWS
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 TYPF,
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
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
THIS IS AN APPLTCATION 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 pennit and work is not to start witl�out a pennit on site; that the woric will be in accordance with the
approved plan in the case 11 work which requires review and approval of p� d J�
SIGNATURE OF APPLICANT PRiNT NAME .J0 ��E � Z��–I C'� DATE I I'��/ �� 1
APPROVAL INSPF.CTnR STC: T iRF
PLEASE NOTE:
TE PERMITS ARE REOUIRED FOR
ELECTRICAL AND MECHAMCAL WORK
S��ob�� .-1� �Io�o��� .� �D(o .�y NDV 18 20�1
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