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Inspections RESIDENTIAL APPLICATION Received By: �{,
763-572-3604 CITY OF FRIDLEY vat 'c1:
763-502-4977 FAX EFFECTrvE i-i-aoii �� �
DATE / '� � � YOURE-MAILADDRESS �Jp(2i,L� (_a%o�Q �yi
siTE aDDt�ss 3�i I��n � ni� �,1 i,,. � rvti�J C"ct�f ���
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
1NSURANCE
PROPERTY TYPE
PERMIT TYPE
O OWNER UC�ONTRACTOR
ADDRESS: 3� ( �v�' lj/'�
PHONE:_� b 3- S'7l' ��7 �
STATE
PHONE ! bj `'�,f �I "' b l� l
�INGLE FAMILY/NEW CONSTRUCTION
O TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH ,�FROOP
❑ DECK ❑ SIDING
CERT
1 CITY�
Fax 7�3 ° `(3 �%-.i
SIZE
S'TORIES
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �.t1 �(�- �
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING I _� J�.'IiOUSE ONLY
NUMBER OF SQUARES _ V� ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
'ATE %�ZIP
a/�°j
TE�%VZIP .,�5_ �(fj�
FT
BASEMENT REMODELING SUBMIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHE SUBMIT•
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2 Two t f t I
se s o cons ruction p ans
WINDOWS ' 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE 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:
� (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ C�.. l� OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
, TYPE
$ �, , 2.� 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)
$ $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 ( )
$ '1'1.15 Make checks payable to: Citv of Fridlev Atta�
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 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 wo�hich req ires review and approval of plans;p +
SIGNANREOPAPPLICANT�M �,_AQY.ha�j ��,,,�Ce,�y�I�Sp�NTNAME_ Y��f�Gv� PCQ�SS Dp� ��30��1
APPROVAL INSPECTOR SIGNATURE