P - 45307Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ( " �� ° � �
BUILDING
RESIDENTIAL APPLICATION
SITE ADDRESS � J U tf?tGf := � �
TH[S APPLICANT IS: ❑ OWNER
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
CITY OF FRIDLEY
EFFECTIVE 1-I-201 t
YOUR E-MAIL ADDRESS
NAME: �%� �.c'. � i.ti h v\
ADDRESS:
PHONE:
NAMb: L►-�-T.'TS �'"�" "1 1 G h��1�!
STATE LICENSE # �U�� % �� (p
ADDRESS: I `i �I 3 ✓�'� �' <
PHONE �C% � �- ��.�' (� �' c� �
� SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
CITY
Permit No.:
Received By: �" �
Da���'� U L �.
STATE ZIP
LEAD CERT NLIMBER
CiTY j�� +�-� L�� �C..c STATE Jnn�IP c� 5,3� �
SIZE
❑ ADDITION ❑.GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH t-� ROOF ❑ Dt2ATN TILE
❑ DECK � ❑�`IDiNG ❑ OTHER
❑ SWIMMING POOL
TY.PE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
a MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _�
GARAGES
PROPOSED SIZE:
PROPOSBD HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
W IDTH
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADD1TiONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR W[NDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(U5ING 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
$ �3-�1�
$
$
$
$
$
$
$
$
$ �--�—
$ Q(A�"15
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= Sx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreernent necessary ( ) Non Necessary (
Make checks payable to: City of FridleY
Attach
THIS IS AN APPLICATION fiOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 acknowledge that the information above is complete and accurate; that the work will be in
confortnance 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 ermit and work is not to start without a permit on site; that the work wil] be in accordance with the
approved plan in the case of all �ch r uires review and approval of pla� j ��� .7 ^�d ^,�
SIGNATURE OF APPLICANT PRINT NAME 7`C� DATE
APPROVAL INSPECTOR SIGN U --