P - 45380Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY /J��-�
EFFECTIVE 1-1-2011 d i
DATE C�+ ( _ YOUR E-MAIL ADD{2ESS
SITE ADDRESS _ � L��o C. L�C.i���L�V.: Cj� ���'i
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ N,�qE:���, � L� A,�� C�_�.�j��
TENANT pDDRESS: -�j �3 � �, (.: L�t-'N�j ��4.V �`
PHONE: �G�� — SrIZ - �v �"�-"%
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
NAME:__��
STATE L[CENSE #
crTY
T
fwurcr.��: r-� i !G�' � v�.�t� t,s CTTY�
PHONE /'"" � pq}�
❑ SINGLE FAMILY/NEW CONSTRUCTION � SIZE
❑ TWO FAMILYlNEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRA[N T]LE
❑ DECK p SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
LENGTH WIDTH HE
ROOFING
NUMBBR OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
', IN EXISTING OPENINGS ❑Yes ONo
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
� TYPE OF WINDOW TO BE INSTALLED
�dHOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
Permit No.:
Received By: �
Date Rec'd:�
TATE Gl�. �IP 5?�2L
ATE�ZIP
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
i. Site P1an/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE ST[CKER 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 TYPE
Permit Fee $ "�� See Back Page for Fee Schedule
Plan Review $ ` 65% of Building Permit Fee
Fire Surcharge $ f .001 times the total job valuation
Surcharge $ 1,. .00OS x Permit Valuation Minimum $5.00
License Surcharge $ ,r� (}��— $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
I Totat Due $ �: �— Make checks payable to: City of Fridley Attach Stiaulations
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 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 work hi h requires review and approval of plans.
SIGNATURE OF APPL[CANT � PRINT NAME DATE
APPROVAL INSPECTOR SIGNATURE ...� rJi� i-