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Building
Inspections
763-572-3604
763-502-4977 FAX
DATE • ?jO I
S1TE ADDRESS F33c
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT[VE 1-1-201 ]
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/ NANtE:�4�,
TENANT pDD�ss: �an
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK
DESCRIBE WORK BEING DC
SIZE OF IMPROVEMBNT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDIIVG
❑ Vinyl
❑ Aluminum
❑ Otkter
STATE LICENSE
Permit No.`.
Received By: �U �
Date R��� � � � � �. � � �
YOUR E-MAIL ADDRESS � �(�,�.cSC 9'/y10,�,r�• CQ JM
C�FONTRACTOR
+ . i �.
( $ i.�l i
STATE ZIP
CEItT NUMBER �p�T-2.3 2 °��j � 1
CITY �O11 _ Uf�� STATEI��ZIP _��
PHONE �IJL'75"l►•_i�IUV FAX `%5L'D`I�•
� SINGLE FAMiLY/NEW CONSTRUCTiON SIZE
❑ TWO FAMILY/NEW CONSTRUCTtON STORIES
❑ ADDITION ❑ GARAGE/SHED WINDOWS
� BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDTTION
C�Z( MAINTENANCE/REPAIR ❑ REMODELING
^'—' - � - . . _ _ . L • _
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
FT
BASEMENT REMODELING SUBMTT:
1. Existing Floor Plan
2. Proposedfloorplan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Sofft ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structttres
and proposed project.
❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS i�Yes ONo LOCATTON OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF ��n , hc�I �5�2�� MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED I� I� NUMBER OP WINDOWS �0
ALL FEES ARE BASEb ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 00 , �^' OCCUPANCY TYPE
Permit Fee $ 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 $5.00
License Surcharge $ � $5.00 (State Licensed Residential Contractars)
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 --$ i�c�— Agreement necessary O Non Necessary O
Total Due � � � � �� � p� Make checks navable to: Citv of Fridlev Attach Stiuulations
THIS IS AN APPLICATION FOR A PERMiT-NOT VALID UNTIL PROCESSED
I hereby apply far a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ardinances 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 ork i requires review and approval of p� an�s�.� ��"
SIGNATURE OF APPLICANT � —.�� PRINT NAME NIlll.� `�' 41/. h��DATE ZO Xy� •�JI
APPROVAL INSPECTOR SIGNA U . ��
AND