P - 47812Building
Inspections
763-572-3604
763-502-4977 FAX
5�.�5
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
DATE �•J �n e. 20 l I
SITE ADDRESS i e1(eCf Qn :.�e J� �_ /� L.� e
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMiT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
iNSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
❑ OWNER
�-�-zo� i
Permit No.:
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YOUR E-MAIL ADDRESS (�ip�{,� . q�� �T Z� �► q m�� C�+
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�ONTRACTOR
NAME: Q�e� n�.y
ADDRESS:_� y�.: �. nh �
CITY STATE ZIP
PHONE:_ 1�63. 3.p y l{I.�-�{,�
NAME: C1Q� �S WlrtdpyJ �' � i��t�A
STATE LICENSE #� ` L�AD CERT NUMBER NACT "
ADDRESS:_,1�(�(� 1.� AIIh��� Li�/G � � "'
52. Q, �� � �(�� CITY�� �pjV.� STATE�_ZIP�L�
PHONE - � --_�--
FAX `.�
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION �T�,,,,,-�
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
� MAINTENANCE/REPAIR
DESCRIBE WpRK BEING DONE: �C. ���,e.
SIZE OF IMPRnVFna��.rT
❑ GARAGE/SHED WINDOWS
❑ ROOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ ADDITION
❑ REMODELING
ROOFING "`' "" n HEIGHT SQ FT
NUMBER OF SQUARES � HOUSE ONLY
❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT�
GARAGES ❑ ATTACHED GARAGE 1- Existing Floor Plan
PROPOSED SIZE: ❑ DETACHED GARAGE 2 1'roposed floor plan
PROPOSED HE[GHT: 3. List of structural members Co be used
SIDING
❑ Vinyl FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Aluminum ❑Soffit ADDITIONS & PORCHES SUBMIT:
❑ Other � Tnm 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
WTNDOWS 2. Two sets of cousttuctiou plans
TN EXISTING OPENIIVGS �Yes ONo 3. Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF LOCATION OF WINDOWS FOR WINDOWS – PROViDE U-VAWE AND
OPENING CHANGES & MANUFACTURE STiCKER ON WINDOW.
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 $ � pp ��
I Permit Fee m --�, OCCUPANCY TVPF
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� �I `i �`� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ i .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+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessa
$ ry ( ) Non Necessary ( )
�1 Make checks payable to City of Fridle Attach
THIS IS AN APpLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED r ,
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 ll wor w' h�requires review and approval of plans.
SIGNATURE OF APPLICANT '
APPROVAL INSPECTOR SIGNAT R PRINT NAME�.��� �((,j �'���{ �`1'y� DATE���r ��
PLEASE NOTE: SEP RATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK