P - 45766Building BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-I-201I
DATE � /"ZR � /� YOUR E-MAIL ADDRESS �'v e � �s�.: �
s�TE �DRESS _S� � r �„� S-� kJ� �..-, `�/,� �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
❑ OWNER
NAME:
ADDRESS:
PHONE:
CITY f—/' .�
Permit No.:
Received By:
Date �� ,
c�,t2> .�2
ATE�ZIP s—s y3?
NAME: � �3 S �.� -�-e rr ,` c� R �U f" �'�.� a°'�s ��.f �-
STATE L[CENSE # �Z(7 ��(��/ �' LEAD CERT NUMBER bi7� LU�C'� —�Q� J[� ��
ADDRESS: �� 7_"Z F{r�-C�pr S'I�' �%[� CITY r�j�'�pk STATE����`LIP��
PHONE pq}(
INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION �ARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH OOF ❑ DRAIN TILE
❑ DECK IDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �,rj.,,_,_�
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING �7, HOUSE ONLY
NUMBER OF SQUARES _�_ ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
g�o o ° �
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
O Trim
❑ Fascia
LOCATION OF W[NDOWS
NUMBER OF
HEIGHT
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)
TOTAL 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�
$ �.
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the tatal 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: City of FridleY Attach
THIS IS AN APPL[CATION FOR A PERM[T-NOT VAL1D UNT[L 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 ork w ich requires revie and approval of pl s. _�('
S[GNATURE OF APPLICANT �C �����(�PRINT NAME �coi� �r��e ( I DATE _ �
APPROVAL INSPECTOR S[GNATURE