P - 46268Building BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFEC�ivE �-�-ZO>>
DATE � ` �� " I � YOUR �MAIL ADDRESS ��v � �J�GC� �jC �
SITE ADDRESS � 77 � � S�" . /V. � •
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/ NAME:
TENANT , r���,,,, :,;
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
S�. �l. E. ci-r�r
PHON�: �p� - S� I' �� 3 S
S?A►'E LICENSE
PHONE 7�3 ' 3 I�"�9� C�
INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAM[LY/NEW CONSTRUCTION
❑ ADDITION O GARAGE/SHED
❑ BASEMENT FINTSH r�00F
❑ DECK ❑ SIDING
❑ SWIMMING POI
TYPE OF WORK: I❑ NEW HOME
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES � �
GARAGES
PROPOSED SIZE:
PROPOSED HEiGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ADD[TION
O HOUSE ONLY
�'1-IOIISE & GARAGE
❑ ATTACHED GARAGE
O DETACHED GARAGE
bl�
Permit No.��
Received By•
Date R � �
Pfp/' • CU �
STATE ZIP
LEAD CERT NUMBER
CITY {%�%,
FAX 7�3 31s_
SIZE
STORIES
❑ DRAIN TILE
❑ OTHER
HEIGHT
ATE/�AIZIP�� (�
Sf� 8'
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
�offit ADDITIONS. & PORCHES SUBMI'f:
Trim I. Site Plan/Survey showing the existing struchzres
���a and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE iJ-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACNRE STICKER ON WINDOW.
OPENiNG CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS;
SIN �I� 1997 U.B.0 FEE SCHEDULE)
7'OTAL JOB VALUATION $ I ^ OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ Q .001 times the totai job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Emsion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main �harge $ Agreement necessary O Non Necessary O
Total Due $ �� Q Make checks aavable to: Citv of Fridlev Attacl
7j
"', ��
1
THIS IS AN APPLICAT[ON 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 of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f it nd rk 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 ic ire review and approval of plans. 7 /'
SIGNATURE OF APPUCANT PRINT NAME �iQ�L J-��� DATE �O —���I
APPROVAL INSPECTOR SIGNA RE