P - 45371Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ( ' S ' �
SITE ADDRESS �
THIS APPLICANT IS:
- I PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-20ll
YOUR E-MAIL
❑ OWNER
ADDRESS: / lP�� C� L! / �,�. .JA� l I L� CITY_
PHONE: � „� —S � � ' � � '� �'
CONTRACTOR NAME: " �'«'���i� �-� •
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICE/NS/E # LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: �f' / CITY�
INSURANCE pHONE � S I - �? � -- Cv FAX � - �T �
PROPERTY TYPE NGLE FAMILY N SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �0 R} OF ❑ DRAIN TILE
❑ DECK H'SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ ADDITION
Ck1G{AINTENANCE/REPAIR ❑ REMODELING
� S
Received By:
Date Rec'd:
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STATE�' � ' "ZIP � �`T � �
� sSTAT� Z�ps v �
-�1�,�0
� DESCRIBE WORK BEING DONE: U e�a�-��
SIZE OF IMPROVEMENT ENGTH WIDTH HEIGHT SQ FT
.. ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & 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 HEIGHT:
SID FOR NEW CONSTRUCTION INCLUDING DECKS,
myl ❑Soffit ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. 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 ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENiNti �.HANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USIN�THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ GY) � OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ 7, (,�Q .001 times the total job valuation
Surcharge $ 3�� .0005 x Permit Valuation Minimum $5.00
License Surcharge $ �• V° $5.00 (State Licensed Residential Contractors)
, SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$24 =$
Erosion Control $ $450 Conservation Plan Review
_ Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Dne $ � Make checks pavable to: City of Fridlev Attach
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 1 understand this is not a
permit but only an application for a permit and w k is not to art without a permit on site; that the work will be in accordance with the
approved plan in the case of I r whi� re ' re 'ew a approv of plans.) •,.,/ �/� DATE �• � 1`
SIGNATURE OF APYLICANT PRIN AME c� K��r /
APPROVAL INSPECTOR SIGNA
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