P - 35178Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � l �^
S1TE ADDRESS �c�
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20] i
YOUR E-MAIL ADDRESS
❑ OWNER ,.�ONTRACTOR
PROPERTY OWNER/ NAME: fi'h �
TENANT ,q.pDRESS: S Y�J
PHONE: 49 � L 9g�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
iNSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEiNG
�
Permit No.:
Received By: ��' ��If`l
Date R��� � � �. � � �
CITY �` ; Gr hy STATEnN ZIP S�7z /
�-
STATE LICENSE # ZO�/L�L,�i� LEAD CERT NUMBER
ADDRESS: ��� �/ O I�� S� ,.�� CITY �Z%G� STA'�ZIP�
PHO1dE �G,� (� 76 r`� 33 5 Fa,x 6 iz ��'/—S�''Ye/
31NGLE FAMILY/NEW CONSTRUCTION
TWO FAMILYMEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
$3�AMTENANCE/REPAIR
_. �o� /' � �Fc.
'Ll SIDTNG
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
ROOFING g HOUSE ONLY
NUMBER OF SQUARES �_ O HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: � DETACHED GARAGE
PROFOSED HEIGHT:
SIDING
❑ Vinyl OSoffit
❑ Aluminum ❑ Trim
❑ Other O Fascia
WINDOWS
IN EXISTING OPENINGS OYes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
❑ WINDOWS
❑ DRAIN TI[.E
� OTHER
�
U.v �
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDTNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of conswction plans
3. Energy Calculations
FOR WfNDOWS – PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBBR OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USTNG THE 1997 U.B.0 FEE SCHEDULE)
fOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$ �
$
$
$
$
$
$
$ �' � ,
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 Residentia! 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: City of Fridle_y 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 comptete 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 all w which re uires review and approval of plan �j
SIGNATURE OF APPLICAN7 �����f�. PRINT NAME �/I �U/.l DATE %— �) /
APPROVAL INSPECTOR S[GNATURE T �—