P - 35754Building BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE� ~J °' l� YOUR E-MAIL ADD1tESS
SITE ADDRESS y(V / CD � ' - .
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
❑ OWNER �CONTRACTOR
NAME: („/�' �'7 /�'l� i 7 c. �
ADDRESS: Y CITY
PHONE:
Permit No.:�z�V
Received By:
�. • �
-, "�"' - r
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ATE ZIP
NAME: c�'�L�t (��L.{ ��� X�� w � r rt�ti�v��+�n ��
STATE LICENSE # o?O % 3�%c� i�p LEAD CERT NIIMBER
ADDRESS: f Y$�Y � y'� �� rS'�" CITY l� "n L� l�C STATE�"�/�LIP�
PHONE %�D.� ' ��/ �- �iD�J'�i Fax
❑ SINGLE FAMILY/NEW CONSTRUCTION �- SIZE
O TWO FAMILYMEW CONSTRUCTION ^ STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ROOF � DRAIN TILE
❑ DECK ❑ 1NG ❑ OTHER
❑ SWIMMING POOL
O NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
ROOFING
NUMBER OF SQUARES � �
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
❑ Vinyl
� Aluminum
❑ Other
WINDOWS
fN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
OSoffit
❑ Trim
❑ Fascia
LOCATION OF WtNDOWS
_ _ _ _ NUMBER OF WINL
HEIGHT
FT
BASEMENT REMODELING SUBM(T:
l. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION tNCLUDiNG 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)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due _
�
$
$
$
$ J
$
$
$
$
$
$ 1•6
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
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 f a 't d w k is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of w' re re eview and approval of plan ����,��� �^ �^r/
SIGNATURE OF APPLICANT i PRINT NAME DATE
APPROVAL INSPECTOR SI RE