P - 45672Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� �� � I
S[TE ADDRESS ���
THIS APPLICANT IS:
'rl,
BUILDING
RESIDENTIAL APPLICATION
CITY 4F FRIDLEY
EFFECTIVE 1-1-201(
YOUR E-MAIL
❑ OWNER �lCONTRACTOR
PROPERTY OWNER/ NAME:�,
TENANT
ADDRESS:
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
1NSURANCE
PROPERTY TYPE
.-C /I�
STATE LICENSE #
ADDRESS:
PHONE (,�i 3"''�'% l�' �'U �` V
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTTON
PERMIT TYPE ❑ ADDITION
❑ BASEMENT FIN1SH
❑ DECK
TY.PE OF WORK:
DESCRIBE WORK BEING
SIZE OF [MPROVEMENT_
❑ GARAGE/SHED
�' ROOF
❑ SIDiNG
❑ SW[MMING POOL
Permit No.:
Received By: ��
D��c'�����
fTY� /' ��C/` ���C
(1ws ' f , � .
EAD CERT NUMBER
CITY �1��� `
FAX /,FJ 7^ �'Z�"�
SIZE
STORIES
❑ WINDOWS
❑ DRAM TILE
❑ OTHER
C7 NEW HOME CONSTRUCTION ❑ ADDITION
[S MAINTENANCE/REPAIR ❑ REMODELING
ROOFING
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENTNGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENiNG CHANGES &
TYPE OF WMDOW TO BE RJSTALLED
�
❑ HOUSE ONLY
■ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HEIGHT
STATE_ V�ZIP
ATF(NI_�ZIP
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
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 �5
$
$
$
$ �j
$
$
$
$
$
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 aavable to: Citv 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 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 of 11 o c e review and approval of plans. �D !
SLGNATURE OF APPLICANT � PRINT NAME '�Yr►'►t-� �JZ�'�t DATE �� i I/ ��
APPROVAL INSPECTOR SIGNATURE