P - 35771Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � � �
SITE ADDRE S Z
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
6 �T
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-201 f
❑ OWNER
I��L�
YOUR E-MAIL ADDFtESS
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0
�
Permit No.:
Received By:
Da��' �
ADDRESS: Z�S ���� At/p CITYJ rc:�%L u STATE�ZIP���(�Z
PHONE: �6' �j'- rj �Z � C�G% q�
_....., 1ri__/ /1 _! �. . , . � _ . _ .
STATE LICENSE # L O G�L( ���
ADDRESS: LS�O� TC�c� «p_
PHONE `2 —,6 � C — / Z Gf �
�B4SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
❑ BASEMENT F[NISH
❑ DECK
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE: �L —�O� L��'
ROOFING
NUMBER OF SQUARES Z_ � ¢�
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
IDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENWG CHANGES &
TYPE OF WINDOW TO BE INSTALLED
,�ROOF
❑ SiDING
❑ SWIMMING POOL
O ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
,D CERT NUMBEIY —
CiTY R�� STATE�ZIP S�d2�
FAX
�E � o s �
ORIE�
❑ WINDOWS
O DRAIN TILE
❑ OTHER
F7'
BASEMENT REMODELING SUBMIT:
I. Existing Fioor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION lNCLUDTNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. 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
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
.
� �j�
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1i1�
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I hereby apply for a building pi
conformance with the ordinances
permit but only an application fc
approved plan in the case of all w
SIGNATURE OF APPLICANT
APPROVAL INSPECTOR SIGNAT -E
TERIALS:
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 payable to: Citv of Fridlev Attach
lations
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
nit and I acknowledge that the information above is compiete and accurate; that the work will be in
nd codes of the City of Fridley and with the Minnesota Construction Codes; that I nderstand this is not a
a permit and wo is ot to start without a permit on site; that the work will be n accordance with the
k whic iequires u vie and approval of 1 /'
PRiNT NAME�� ��n (� D� ~ ,r DAT� (� F� /r%� / / (