P - 40735Building BUILI)ING
Inspections RESIDENTIAL �PPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX t;rr�:cTivE �-i��oi i
DATE �� ' I �'f"" I �
SI7'� ADDRESS � � "'.i r�
THIS APPI,lCANT IS:
PROPERTY OWNI:R/
"I'ENANT
CONT[iAC7'OI2
SU}3MIT A COI'Y Ol�
YOUR STATE LICGNS[�;
AND CERTIPICATE OF
INSURANCL
PROPERTY TYP1:
PERMIT TYPE
TYPE OF WORK
❑ (I�VN GR
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PIION[_���_ ��(_�#,_..� ��- __ : �A_ PAX
�j_SINGI.E PAMILYMF.W CONSTRUCTION S['!,G ���
❑ "I�WO�'i�?Tl�,' /� CONS'CRUC�I'ION SI�ORIIiS
❑ nDDfI'ION ❑ GnRnGI?/SHED ❑ WfNDOWS
❑ l3/�SCMGN'I� FINISFI ��ROOP ❑ DRAIN TILE
❑ DL'C[� ❑ SIDING ❑ OTHLR
❑ SWIMMING POOI,
❑ NF.W IiOMF; CONS'fItUC'I'ION ❑ nDDI'I�ION
�Mi1W'IENANCE/REPAIR ❑ RLMOD6LfNG
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�'erinit No.`.
Received By:,�
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S i1'1 S"1'A"IE �A.[
DI:SCRI[3G WORK BEiING DONB: _ ?;' ' T ______ --- —
SIZ,GOF 1MYROVEMLN"� _ _ ,.,�-'� . _LGNGI�Ii __ _ WIDT11 _ _ _ IIEIGFI�I SQ Pl� _
ROOFItiG � FIOUSI: ONLY
,�-� � (3ASF MENT RLMODF,C.ING SUI3MIT:
NUMI3L-'R OF SQUARES ��% , �;?�110USI�, & GARnGIi �. E�isting Floor Plan
GARAGr:S ��� ❑ AT"1'ACI�11?D GnRnGE 2. Proposed floor plan
PROPOSED SIZE: ❑ D�Ti1G1II��D GARAGF: 3. List of�stnictural men�bers to be used
----_ --
PROPOSED HIiIGH"I�: -- _—_—
I�OR NF.W CONSIRUCTION INCLCI�ING DGCKS,
SIDING nD[�ITIONS & PORCIIES SUI3MI�f�
p V���y� ❑Soflit I. Site Plan/Surve�y showing the existing 5tnictures
❑ Aluminum d�� ���� and proposed project.
❑ Other ❑ P�scia 2. T�vo scts of construction plans
WINDO\�'S 3. Energy Calculations
�[N EXIS'I WG UPENWGS CJYes ❑No LOCA'I'ION OE WINDOWS I�OR WIIVDOWS -PROVIDF. U-VA(.UC AND
OR C'OR NF,W OPENWGS-DLSCRIL31� SIZE OP ____ __ MANUPnC'fURG STICKER ON WINDOW.
I OPENING CHANGGS &
� TYPG OF W[[�IDOW "I'O [�[: WS"I'ALL[�:D NU+�I[31;R OF WINDOWS
ALL FEES ARF. I3A; FD ON VALUA7'ION, INCLUll[NG T��IE COS7' OF l,ABOR AND n7A'CERIALS:
� (r,lJ�f,t "1'I�>1997 U.B.0 1'EE SCIIEDULE)
TOTAt. J0�3 '�'�.LL' 17'fOr� � (� C.� � QCCUPANC.Y _TYPE � _
— _ _ _ __ _ -- — — — _._.
Pennit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit 1=ee
� Fire Surcharge $ .001 tiines 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 i�1WCC for determination)
Curb Cut Escrow $ ft+ 6 ft �= ft x$25= $
---- ----- —
Erosion Control $ $4_SO Conservation Plan Review
Park Tee $� Fee Determined by l�ngineering
Sewer Main Charge $ ��greement necessaiy O T�on Necessary O
7bta1 Duc $ —�(}$�,�_Nlakc chcciCS ��bte to: Citv of Fr�idlcy Attach Stipalatic�ns
i'(lIS IS nN APPLfCA'f(ON FOR n PFKMCI�-NO"� ViAL,ID UN"fIL PROCESSF;D �
t hereby apply for a buildii ��crmit and I acl<nowledgc that the information above is complete and accurate; that the work will be in
conformance with the ordi � ance and codes of he City f� ridlcy� an with the Minnesota Construction Codes, that I understand this is not a
permit but only an applic tion fo a permit a�� w k�s u�':tart w�thout a�crmit o� sit ; that the work will �in accor�ance with the
approved plan in the case f a71 w whic eq 'r s e vta ��pro al of pl � s. ��� —� �
SIGNATURE OF APPLICAN"I' ' IN A G ��_ _ vAT �-
APPROVAL INSI'ECTOR SIGN TU �
PLEASE NOTE: SEP° ATE E MI'I S FOR PLU BING, ELECTRICAL AND MECHANICAL WORK