P - 35119Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.
Received By:
Date��d:kl:J
�
DATE �/I �/ �� YOUR E-MAIL ADDRESS �l3� C,f �Cra� .�t,��i i2ciced%. G-.pr+,
S[TE ADDRESS _��75�0 � i!� � T— N.i � r'*�r OfGGy
THIS APPLICANT IS: �OWNER ❑CONTRACTOR
PROPERTYOWNER/ N�E: �o�� �to ��-�s
TENANT ,qDDRESS: "� � 3� /Z[ t_L.c ,r.� v t/i'- JlI � CITY i f G� f� STATE �Lt
�i` !^� —6Lztp .i S�/.3�
PHONE: �„�3 �%� „L � ya (o �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
1NSUR.ANCE
PROPERTY TYPE
PERMIT TYPE
NAME:
STATE LICENSE #
ADDRESS:
PHONE
INGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
O BASEMENT FINISH
❑ DECK
TY.PE OF WORK: ❑ NEW HOME CONSTRUCTION
,�'A�AINTENANCE/REPAIR
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
S1DIN
O Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENMGS �'es ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
CERT NUMBER
CITY STATE Z!P
FAX
❑ ROOF ❑ DRAIN TILE
❑ S[DiNG ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim ��� r.�
D Fascia
L� t� iug aw.
LOCATION OF WiNDOWS �% �j�s»�4 .v" ""
NUMBER OF
FT
BASEMENT REMODELING SUBMIT:
i. Existing Floor Plan
2. Proposed floor plan
3. List of sVuctural members to be used
FOR NEW CON3TRUCTION (NCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
L Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction pians
3. Energy Calculations
FOR WINDOWS— PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
-- — -- -
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
J� G THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $�'2C��V OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Contro]
Park Fee
Sewer Main Charge
Total Due
$ `(�' Z5 —
$
$ �
$
$
$
$
$
$
$
$ �
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.00OS 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 Fridiev Attach
THIS !S AN APPLICATION FOR A PERMIT-NOT VAL1D UNTIL PROCESSED
I hereby apply for a building permit and 1 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 a ork w ch r quires review and approval of pl,�ns. /�
SIGNATURE OF APPLICANT ��� PRINT NAME.�O�iN� f�eC(�� �s DATE ��/��//
APPROVAL INSPECTOR S[GNA URE