P - 45384Building BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE ]-1-2011
DATE � YOUR E-MAIL ADDItESS
SITE ADDRESS ��O Z�-C �n 1—` ��1,�-
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
❑ OWNER
NAME: �,�1 �riA � i/� � �'��% �
ADDRESS:
PHONE: �j � Z ' � �e"� �
• .l►l.�u��A
a�
CITY
Permit No.:�
�
Received By:
Date Rec'd: � If�
STATE ZIP
STATE LICENSE # r�Cj(p S_J.� P�O LEAD CERT NUMBER
ADDRESS: I���.� ��✓Y.n � S'� CITY �� L<-C4 STATE .�vt%LIP
PHONE 7(0 �j ' y�(3 ''(�o `7�Y FAX
$INGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ ADDIT]ON ❑ GARAGE/SHED
❑ BASEMENT FTNISH �=RaOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
SIZE
TYPE OF WORK: ❑ NEW HOME CONSTRUCTfON ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES _� ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
' 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
❑ Trim
❑ Fascia
LOCATION OF W[NDOWS
NUMBER OF WINDOWS
❑ WINDOWS
❑ DRAIN TILE
� OTHER
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
���
i��a
�����
��
�
[�i �.l��'/,
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 pavable to: Citv of Fridlev
Attach Stipulations
THIS [S 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 for pe it 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 a] � � ires review and approval of plans�-� ��� '�� ,� ��
SIGNATURE OF APPLICANT PR[NT NAME J iC DATE
APPROVAL INSPECTOR SIG ATURE