P - 47342Building BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECT�vs �-i-zo>>
DATE �e /F G/l� �j
S[TE ADDRESS �h � D `�
TH[S APPLICANT IS: ❑ OWNER
PROPERTY OWNER/ I NAME: e
TENANT ,qDDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME:�
STATE LICENSE #
ADDRESS: � t
YOUR E-MAIL ADDRESS
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Permit No.: � � � L
Received By:l � �
Date R�,� J U N�.: 6 2
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�'� / .
LEAD CERT NLIMBER
i� CITY '�
PHON � � P F� . �
IN LE FAMILYINEW CONSTRUCTION SIZE �CTj �
O TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GAR GE/SHED ❑ WINDOWS
❑ BASEMENT FINISH OF ❑ DRA[N TILE
❑ DECK ❑ SIDING � OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ! +�'
SIZE OF IMPROVEMENT__��1�
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TvnF nF wn.innW Tn RF iNSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF
HEIGHT
T
t •�
� 1 �,-� �-�-
FT / �`1 � `�!
BASEMENT REMODELING SUBM[T:
l . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION R�ICLUDTNG 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 WINDOWS — PROVIDE 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)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tntal nne
$ �,j,�rj See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ j� .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 ( )
� q Make checks navabie to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D 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 applicat' n for a per ' ork is not to start without a permit on s�e; th t the work will be i ccord nce with the
approved plan in the case o all work 'ch e uir r v'ew and approval of p ns. � �
SIGNATURE OF APPLIC PR1NT NAM ' DATE
APPROVAL INSPECTOR SIGNA R
1