P - 35834Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE YOUR E-MAIL ADDRESS
SITEADDRESS���7(� �Lj �����, �-(1 n��U
THIS APPLICANT IS: � OWNER ❑CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
Permit No.:
Received By:
.
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[vAME: J �J 1.._ 1 O j' Q r ed '"Z
ADDRESS: 3 j.� 7�/� /j t/� �1 Tx' C(TY �' %'� �_� (_� STATE�z�p 3°s Y3 Z
PHONE: % � � ��� 9 �%Z�_
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: CITY
PHONE FAX
,R'SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/{�IEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ W[NDOWS
❑ BASEMENT FMISH J� ROOF ❑ DRAIN TII.E
, ❑ DECK ❑ SIDiNG ❑ OTHER
TYPE OF WORK: `
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR f�REMODELING
: • %f � 7 .in s� ,�i_ ./1 I!� � i't f. ,�
ROOFING
NUMBER OF SQUARES ,�, �
GARAGES
PROPOSED SIZE:
PRQPOSED HEIGI-iT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
� DETACHED GARAGE
OSo�t
❑ Trim
� Fascia
WINDOWS
iN EXISTING OPENINGS DYes �No LOCATIQN OF WINDOWS.
OR FOR NEW OPENMGS-DESGRIBE SIZE OF
OPENING CHANGES &
TYPE OF W[NDOW TO BE 1NSTALLED NUMBER OF V{
HEIGHT
ATE ZIP,
�
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2: '� Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDiNG 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 WMDOWS — PROViD£ 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)
COTAL JOB VALUATION $ OCCUPAPICY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Bui(ding 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+68= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: Citv of Fridfev
Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a building permit and I aclrnowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances a.nd codes of the City of Fridley and with the Minnesota Construction Codes; that I under�tand this is not a
permit but only an application for a�ermit 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 1 ' ' s review and approval of plans. � �'1� S, „� � S
SIGNATURE OF APPLICANT Cr � PRINT NAME_�n�� � \ � �t�_ �_DATE" (� --.
APPROVAL INSPECTOR SIGNATURE