P - 42214Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-i-2010
Permit No.: � � � � , �
Received By: ��'1
�� �'�.��, ��
DATE_ � /„L �/U YOUR E-MAIL ADDRESS �!
SITE ADDRESS ��j.�C/� '� �..SiT/f A-i/E N� �'/�LDL� y��! �y�
THIS APPLICANT IS: �,OWNER QCONTRACTOR
PROPERTY OWNER/
TENANT �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
ADDRESS: �Lj?� ^ �?S�'J`/f �}�� JJ�,CITY �RI�L..�_� STATE�/�ZIPSSY32
PHONE: �,6 �'— �L/— LI,3,C��
STATE LICENSE
EXP DATE
ADDRESS: CITY STATE ZIP
PHONE FAX
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORII
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
�MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
SIZE OF
R OFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
�myl
O Alummum
❑ Other
❑ GARAGE/SHED ❑ WINDOWS
O ROOF O DRAIN TILE
IDING O OTHER
SWIMMING POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
OSoffit
❑ Trim
� Fascia
wnvnows
IN EXISTING OPENINGS C]Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF �
ALL FEES ARE
TOTAL JOB VALUAT��
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
i Sewer Main Charge
� Total Due
�I�Tir`.�i
BAS$MENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floorplan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT.
1. Site Plan/Survey showing �e existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ON V LUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
,,,, �S�'N�iE 199�U.B.0 FEE SCHEDULE)
$`' '� B�j 2.S ' 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)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ 8+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ a Make checks pavable 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 understsnd this is not a
permit but only an application for a permit and work 's n t to start without a permit on site; that the work will be in accordance with the
approved plan in the case of a�l work ich req ' s r ' an proval of pl )
SIGNATURE OF APPLICANT � T NAME �LFD/�li'�.D U. �ATE �( �^—%Z "II.�
APPROVAL INSPECTOR SIGNATURE