P - 39613Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
R.ESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20ll
DATE � (v " � O l < YOUR E-MAiL ADDRESS
siTE ,4DDxESS _ /k� J � � _3 � /� U-�' /V �- 1—►^ jG! L :�-�-i <'yi �� ,j <� `T =7 'z-
THIS APPL[CANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
�WNER ❑CONTRACTOR
NAME: i�� �'J �" � � /J �' l�YJ � ��
Permit No.: ��' � �'� 1 �
Received By: jV I U�k�
Dat��ad.�d.��` � �"� ��� � � 1'�
ADDRESS: /�• � C� 7 v? -� %L� %7/.= CITY� �,%`L'�'-y STATEl2�y ZIP .j �`s T�
PHONE: 7�; , S� ., 7,,1�j�CJ '— 2 j''7' ( G! 2— 3G �-� il�
NAME:
STATE LICENSE # LEAD CERT NUMBER
ADDRESS:
PHONE
�INGLE FAMILY/NEW CONSTRUCTION
� TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE � �DITiON ❑ GARAGE/SHED
� BASEMENT F[NISH �dF
O DECK ❑ SIDING
❑ SWIMMING POOL
CiTY
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WOR� ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�[L1oTX�INTENANCE(REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �-,-� /�� �
EtOOFING
NUMBER OF SQUARES _� �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
B�tO�1SE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
❑ Fascia
WINDOWS
TN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
ATE ZIP
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION (NCLUDING 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 W[NDOWS — PROVIDE U-VALUE AND
MANIJFACTURE STICKER ON WINDOW.
TYPE OF WiNDOW TO BE INSTALLED NUMBER OF WINDOWS I
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Sarcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ I �1� G.�i
$
$ L�
$ 0310
$
$
$
$
$
$
$ 11 �,
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: City of Fridley Attach
lations
THIS IS AN APPLICATION FOR A PERMIT-NO? 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 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 all work which requires review and approval of plans. �,�1/
SIGNATURE OF APPLiCANT l✓,o�,.0 ,��� PRiNT NAME f��l0�/�OiH'JU/ ` DATL-�j� G` 2c'T/
APPROVAL INSPECTOR SIGNATU— R