P - 39570Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �' � Y ` l f
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
SITE ADDRESS '�� �I � (,� � `i �' � E.
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:
YOUR E-MA1L ADDRESS
❑ OWNER �ONTRACTOR
Permit No.:
Received By:
Date Rec'a:
NAIvtE: ��✓ w-cy R� �., 1��e�c, �v„� t
ADDRESS: � 9 '� `� �,2 �... S � �, C CITY `�-�--,,' -) STATE �L� ZIP :5���/ � �.
PHONE:_j �.9. t'�� � J`�c,_. ° `�.G'�.��
,
NAME: _ tTZ,w� Ft�.::.�. �`��e.rr'cA'�'� e�
STATE LICENSE # ��-�.`(,� �C' � 3� LEAD CERT NUMBER
ADDRESS:
,� UG4' "
CITY E,ti:� Cct�-° STATE�S►'6j ZIP $'S��/ 72
F�c Y7f. ) – �r 3 �/ � `'i ��/ 7
C�fiLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCT[ON STORIES i
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH C�6@F-� ❑ DRAIN TILE
❑ DECK ❑ SIDiNG ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �:.- —
ROOF7NG �'�
NUMBER OF SQUARES I --�'
GARAGES
PROPOS�D SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyi
O Aluminum
❑ Other
'k�'hEAUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes I�No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION INCLUDING 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.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ S, �� � aZ�O �� OCCUPANCY TYPE
Permit Fee
� Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
�I 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+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � Make checks uavable 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 applicati 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 ca of all rk e ires review and approval of plans.
SIGNATURE OF APPLICA�T ,,,� PRINT NAME `��C�,-•-��. l��.�.�✓%t:,.l DATE �, z-`E' I(
J ��,� � '12 j � 5.�