P - 35329Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � r — ��� `
SITE ADDRESS ��
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
� � � ��
BUILI)ING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
� YOUR E-MAIL ADDRESS
> Y'-�1�� ('��- `N `�.
❑ OWNER i�ONTRACTOR
NAME: V
ADDRESS:
PHONE: ��' �,(�I^C1"IC��
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STATE LICENSE #
ADDRESS: i
P�iONE L u.+�� �l `c..�Sf
�SINGLE PAMILY/NELV CONSTRUC; ION
O TWO FAMILY/NEW CON3TRUCTION
FAX ''
SIZE
EXP DATE
Permit No.:
R���'��
Date ec' d:
ATE ZIP
A
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH OOF ❑ DRAIN TILE
❑ DECK SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITIpN
❑ MAINTENANCE/REPAIR �REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
FIN � HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �_ ❑ HOUSE & GARAGE
1. Existing Floor Plan
GAI2AGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DBTACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminwn
❑ Other
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. EnergyCalcutations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USIN�T 1997 .B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ t� �� OCCUPANCY TYPE
Permit Fee $ 1 • See Back Page for Fee Schedule
Plan Review $ ' 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $.50
License Surcharge $ � $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2000 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft = ft x$21 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ � 1a , 52C1 Make checks payable to: City of Fridle.y Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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 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 a11 work which requires review and approval of pla
SIGNATURE OF APPLICANT � IJ�� ! 1 LtA �tA Q �(�aA� PRINT NA1vIE �v � rI� �� C?��T 1�ATE ���(� r J U
PLEASE NOT'E: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK