P - 47733Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE �j. �/�/ ���� ( YOUR E-MA"�1[L ADDRESS c{ S c� /�
S[TE ADDRESS � � � O g �!� o � �,I r � � � �-^ �} �
THIS APPLICANT IS: ❑ OWNER Qa$,ONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME:
r
Permit No.:
Received By:
Date Rec' d:
i�
ADDRESS: (� �' S G i� a�E�G (c i�(,�w /)I° N�� _'r
�CITY �— t f% STA
PHONE: % � -- � � c]— �,3 � (�
r" S CJo,Z S`fvil C�'� o•� L-L� G�
ZIP SS
STATE LICENSE # 2. 6� �' LEAD CERT NLIMBER
ADDRESS: ��3 �t�`y1 (,( �'�� � CITY i,cic7OU STAT�ZIP `�J� I%
PHONE tE� �^��� "q' 2. 6 FAX
�9'SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES�_
❑ ADDITION ❑ GARAGE/SHED ❑ W[NDOWS
❑ BASEMENT FINiSH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES ,'3 �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
�, v �a o + hc� � ¢ � ,-!-4�
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE 1NSTALLED
❑ HOUSE ONLY
(�FIOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WiNT)(�w.S
•i�c 1� � � �'� �1,� .
HEIGHT
BASEMENT REMODELING SUBMIT�
l. Exis[ing Floor Plan
2. Proposed floor plan
3. List of stnictural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS, & PORCHES SUBMIT
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
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 TYPF.
t�ermrt ree
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
���
��1�
.. �
.� �,
�
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See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residentiat Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks payable to: Citv of Fridlev
Attach
lations
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
permit but only an application for a permit and w rk is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all wor eview and approval of plans. r
SIGNATURE OF APPLICANT PRINT NAME �� t�� �tiV �(S Iy DATE 6 �� �� I
APPROVAL INSPECTOR SIGNATURE v
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