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Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'd:
763-502-4977 FAX Er�ECTI�E 1-1-2011
DATE 1- S�( I YOUR E-MAIL ADDRESS '""
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THIS APPLICANT' IS: WNER ❑CONTRACTOR
PROPERTY OWNER/ NpME: -�h vM 0.� (� � � y� �� �� �-o •'�
TENANT aDDxESS: �C:��: S t'�
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CONTRACTOR N,�„�:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
1NSURANCE pHONE FAX
PROPERTY TYPE ,�'SINGLE FANIILY/NEW CONSTRUCTION STZE
Q TWO FAMILYINEW CONSTRUCTION STORIES '
PERNIIT TYPE ❑ �DITTON ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH b11 ROOF � DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMNIIIVG POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCE/ftEPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: N`i.i S In : o. 41 �-S
�
SIZE OF IMi'ROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING Q HOUSE ONLY
NUMt3ER OF SQUARES �� � HOUSE 8c GARAGE BASEMENT REMODELING SUBMIT:
1. E�sting Floor Plan
GARAGES p ATTAGHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: p DETACHED GARAGE 3. List of struchual members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
O Vinyl ❑Sotiit ADDITIONS. & PORCHES SUBMIT:
O Aluminum O Trim l. Site Plan/Survey showing the existing structures
O Other ❑ Fascia and proposed pmject.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTTNG OPENR�TGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE ANI1
OR FOR NEW OPEI�IINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPErIING CHANGES &
TYPE OF WINIX)W TO BE INSTALLED N[JMBER OF WINDOWS
�u.L r�r:� ax�: na��:U u�v v2il..uA�1'iV�l, llvI:LUDllvIT'1'li�; C:U,`i' Ur' LABUH ANll MATERIALS:
�(I,�6IN� THE 1997 U.B.0 FEE SCHEDULE}
TOTAL JOB VALUATION
Permit F�
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
TYPE
$" i,/ ,� 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 (Staxe 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 ( )
�%� e: - � I l!/ Make checks navable to: Citv of Fridlev Attac
THIS IS AN APPLICATIaN FOR A PERMIT-NOT VALID iJNTIL 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 appiication 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 of a ork which requires review and approval of plans.
SIGNATURE OF APPLICAS�L1---- PFtINT NAME %M Be�n ol �S� � DATE °l S- 1(
NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHArTICAL WORK