P - 42152Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:
Received By:
Date Rec'd:
DATE��3iZ f C? ; L� i 1 YOUR E-MAIL ADDRESS t1�r�� rUqr�.rt�ss L' i�►1 SI1 • Gos'►1
SITE ADDRESS �OCS fc�3 � �V� N� � ��� r�«y � � � fi ,S � � Z
THIS APPLICANT [S: {Zj OWNER �CONTRACTOR
PROPERTY OWNER/ N,�lvtE: ��-1 R tS 8�1 �R � 1'Tb
TENANT qDDRESS: '�b4 � r'd I�V� NG CITY ��i�CEy STATE IyLNZIP .�Sy3L
PHONE: $l8- �%Bl • .36�5
SUBMIT A COPY OF
YOU1Z STATE LICENSE
AND CERTIFICATE OF
INSURANCE
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: CITY STATE ZIP
PROPERTY TYPE ¢0 SINGLE FAMILY/NEW CONSTRUCTION SIZE
tl TWO FAMILY/NEW CONSTRUCTION STORIES /
PERMIT TYPE ❑ �DrrioN
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
I�MAINTENANCE/REPAIR
L1 CiAKAGE/SHED O WINDOWS
6�ROOF ❑ DRAIN TILE
9� SIDMG ❑ OTHER
❑ SWIMMING POOL
O ADDITION
❑ REMODELfNG
DESCRIBE WORK BEING DONE:_ SN//JG-tBS� S!D/NTr� SoCla'kTT � FAGI p
IMPROVEMENT
ROOFING ��,� L�
NUMBER OF SQUARES .,,_`a+s ;.� \
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDIN�
3� Vinql � �,}
❑ Aluminum ��'� — v�'
O Other � ^--,
WINDOWS
IN EXISTING OPENINGS ❑Yes C7No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE iNSTALLED
ALL FEES ARE BASED ON V
fOTAL JOB VALUATION $ ' �
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
C] HOUSE ONLY
�' HOUSE & GARAGE
❑ ATTACHED GARP.GE
❑ DETACHED GARAGE
6!(Soffit
� Trim
d Fascia
LOCATION OF WINDOWS
HEIGHT
FT
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 & PORGHES SUBMIT
l. Site Plan/Survey showing the existing suuctures
and proposed project.
2. Two seu of wnstruction plans
3. Energy Caiculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
NUMBER OF WINDOWS
ATION, INCLUDING THE COST OF LABOR AND MATERIALS:
G THE 1997 U.B.0 FEE SCHEDULE)
OCCUPANCY TYPE
$ � i�3� a5
$
$ _
$ `
$
$
$
$
$
$
$ "
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$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCF,SSED
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 wo is not start without a permit on site; that the work will be in accordance with the
approved plan in the case of all wo ' h re uires re w d approval of plans. f
SIGNATURE OF APPLICANT . PRI1�T�j�ME� �� � p,�,t (� DATE/r �yI �� I L o►1
APPROVAL INSPECTOR SIGNAT E / �/l U/l 1 ���