P - 37241�
F -� _-�
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE IJ f Id'
SITE ADDRESS _
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL
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❑ OWNER �CONTRACTOR
NAME: � L' Y) � � �
ADDRESS: V � ���
PHONE: �� "
NAME: � � �,"U � (i,�'S `+" �.�
STATE LIC(E'�NSE # Z��(,Q L�.� C1�-} "�
ADDRESS:"lii� �}�I ����►�C✓ ��+
PHONE Z�� �fI Z ' �F�Z� �
CERT
CITY
PROPERTY TYPE �,SINGLEFAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION O GARAGE/SHED C] WINDOWS
❑ BASEMENT FINISH ❑ DRAIN TILE
❑ DECK iFr�"� ❑ OTHER
`O SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION Q ADDITION
°�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DC
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑/�luminun�,-^� „ � �
�Other ���
�-IOUSE ONLY
❑ HOUSE & GARAGE
❑ AT']"ACHED GARAGE
❑ DETACHED GARAGE
Permit No.: y''�' ( i� t��;�
Received By: _:.� ��, _
TA
�ATE�ZIP,
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
?. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDtTIONS. c� PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed projeci.
❑ Fascia 2. Two sets of construction plans
� 3. Energy CalculaTions
IN EXISTING OPENINGS QYes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCIZI$E SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�7 (U THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ `ri��� ��C� 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
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See Back Page for Fee Schedule
65°/a of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Va(uation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
f�+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks aavable to: Citv of Fridlev Attac
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 or a perm' n w rk not to start without a permit on site; that the work will be in accordance with the
approved plan in the cas i r whi r t e and approval of plan�����V-i—����� �`I°'/,_�� U' t�
SIGNANRE OF APPLICANT PRINT NAME DATE
APPROVAL INSPECTOR SIG
PLEASE NO_TE: SE ARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANTCAL WORK