P - 47783Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
DATE� /�/ -/ r YOUR E-MAIL ADDRESS
SITE ADDRESS � � j (,; � ,�� � � �
THIS APPLICANT IS: ❑ OWNER �7`CONTRacTnu
PROPERTY OWNER/ NAME:_
TENANT
ADDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFiCATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
CITY
Permit No.:
Received
ov 1 � ���`i
'ATE ZIP
NAME:__L�Cir'F`i�/�1�C ' LstJ�-7��Z C C.11 i
STATE LICENSE # �j L� y'��( � LEAD CERT NUMBER � 7�j'— �//�y (� -�'
ADDRESS: � %;- ' � ' ` ` - CITY ' STATE�ZIP ��i�
PHONE �� S °,�L 4' .. �.��/5�( FAX
-�• —
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FIN[SH
❑ DECK
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION
S1ZE
STORIES
���F ❑ DRAIN T[LE
SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
O REMODELING
DESCRiBE WORK BEING DONE: �j ��(��'
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT
S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES 3 y. ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT•
GARAGES ❑ ATTACHED GARAGE �• Existing Floor Plan
PROPOSED SIZE: ❑ DETACHED GARAGE 2• Proposed floor plan
PROPOSED HEIGHT: 3. List of structural members to be used
SIDING
❑ Vinyl
O Aluminum
❑ Other
❑Softit
❑ Trim
❑ Fascia
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT•
1. Site Plan/Survey showing the existing structures
and proposed project.
WINDOWS 2. Two sets of construction plans
IN EXISTWG OPENINGS ❑Yes ❑No LOCATION OF WINDOWS 3. Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROVIDE U-VALUE AND
OPENING CHANGES & MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 199'7 U.B.0 FEE SCAEDULE)
TOTAL JOB VALUATION $ nCC"iiPAN!'V m�D�
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
_$ �� �,�`� 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 + 6 ft = ft x$25= $
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ i.� Make checks oavahle tn• ('itv nf Rridl y 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 Ciry 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 a.w k req res review and approval of plan .
SIGNATURE OF APPLICANT �1 �.���� . pI�T NAME ��j'
APPROVAL INSPECTOR SIGNA1VRE / /�� �5��� DATE_�—f��r