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Building BUILDING Pe��t No.:Z�J( -� �
Inspections RESIDENTIAL APPLICATION Received By:,�
763-572-3604 CITY OF FRIDLEY vat��'�t:��� ���
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE ((1 f�� {� YOUR E-MAIL ADDRESS
SITE ADDRESS
THIS APPLICANT IS: ❑ OWNER �I.CONTRACTOR
PROPERTY OWNER/ NAME: , �,f -'�r' (
TENANT ADDRESS: `� * d;7 }� � CITY � STATE ZIP
PHONE: �
CONTRACTOR NAME: � ^
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # T NUMBER
AND CERTIFICATE O�' ADDRESS: CITY STATE ZIP
INSURANCE pHONE � FAX
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTI ' ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF O DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
"�MAINTENANCE/REPAIR ❑ REMODELING
DESCRiBE WORK BEING DONE: Q,�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES _r�_ ❑ HOUSE & GARAGE 1. Existing F.loor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDIN FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim I. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes �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 NELJ AKr: tfAJEll V1V VALUA 11VN, 11VCLUll11VG '1'Hr: CUS'1' UN LABUR ANU MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ D OCCUPANGY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Buiiding Permit Fee
Fire Surcharge $ .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 Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ Make checks pavable to: Citv of Fridlev Attach
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
permii 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 1 w1� k wy�..h,�i�c� requires review and approval of p s. Q
SIGNATURE OF APPLICANT �j � I�YGVUI/t PRINT NAME '�,r ndn �1 �rown DATE� ( I�
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