P - 35839Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � ' O�� � I I
SITE ADDRESS � 9�
THIS APPLICANT 1S:
PROPERTY OWNER/
TENANT
�i.sg`
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011 .
❑ OWNER
NAME:�
ADDRESS:
YOUR E-MAIL ADDRESS
tm�n S-t' NE
�CONTRACTOR
50 rvt riz �
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CONTRACTOR NAME: �
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMB R
YOUR STATE LICENSE
AND CERTIFICATE OF ADD[iESS: 7 CITY i
INSURANCE PHONE I� ' FAX I
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
L7 TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ,�ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: �NEW HOME CONSTRUCTION ❑ ADDITION
TvrnrNTF.NANCF./RF,PAIR ❑ REMODELING
DESCRIBE WORK BEING
HEIGHT
Permit No.
STA
:
A
FT
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ROOFING �HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES � ❑ HOUSE & GARAGE l. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soffit 1, Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No 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 $ OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ p .001 times the total 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= $
Erosion Control $ $450 Conservation P(an Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ �/-, � Make checks payable to: City of Fridle_y Attach Stipulations
THIS IS AN APPI.ICATION 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 ordin es and codes o the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applic ion r a perm a d rk 's not to start without a permit on sit • th the work will be in accordance with the
approved plan in the case f all ork w' e u' r w and approval of plans. � ��� Q'. /�
SIGNATURE OFAPPLICANT PRINT NAME � i DATE O (
APPROVAL INSPECTOR SIG