P - 41226Building
Inspections
763-572-3604
763-SQ2-4�77 FAX
DATE ��/ l� /%/
BUILDING
RESIDENTIAL APFLICATION
CITY OF FRIDLEY
EFFPCTNE 1-1-2011
YOUR E-MAIL ADDRESS
SITE ADDRESS �JQ(� ��y �� /(l�
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
51ZE OF IMPROVF.MF,NT
ROOFING
TIUMBER OF SQUARES _
GARAGES
F'IZOPOSED SIZE:
F'ROPOSED HEIGHT:
SI�ING
❑ Viiryl
❑ Aluminum
❑ Other
iC�,`7 � 7
Permit No.:
Received By:
Date Rec'd:
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ADD�ss: ��'A �/yv � r� �.l,E� cl� �i�/,�a sTa.T�i_�t/ziP S"s11,3_`�_
PHONE:��-- J�lr�"'���%��I
NaME:C�";l�ddccl ���aAts c�,f �i����r��S4�
STATE LICENSE #��%���(f� � LEAD CERT NUMBER �j� �".-;;f '� °tlC���y�,,
ADDRESS:�'y/'��/� ,�� CITY �� /�E�f STATr.���_�%ZIP��
PHONE �p� I� �I �.PS ` C�/�..� FAX �SS%=- 5�C?�•- 1�(/,�
� SINGLE FAMILYINEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
❑ NEW HOME CONSTRUCTION
'�MAINTENANCEiREPAIR
SIZE
STORIES
❑ ADDTTION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN TILE
❑ OTHER
FT
BASEMENT REMODELING SUBMIT�
1. Existing Floor Plan
2. Proposed floor plan
3. List of structuaal members to be use�
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT
❑ Trim l. Site Plan/Survey showing the existing structu-es
❑ Fascia and proposed project.
2 Two sets of canstruction la�
P
WINDOWS 3. Energy Calculations
LV EXISTING OPENINGS �Yes ❑No LOC TION OF WIN WS , FOR WINDOWS - PROi�IDE U-VALL!IE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF � � J MANUFAC"1'URE STIC�ER ON WIN��OW.
GPENING CHANGES &
TY'PE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS 3
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
USING THE 1997 U.B.0 FEE SCHEDULE)
�OTAL JOB VALUATION $ �j �p %O _ __ OCCUPANCY TYPF,
F'ermit Fee
F'lan Review
Fia�e Surcharge
Surcharge
L.icense Surcharge
SAC Charge
Curb Cut Escrow
Exosi�n Control
Park Fee
5ewer Main Charge
Total Due
� `1 FtL.J See Back Page for Fee �cheduIe
$ 65% of Building Permit Fee
$ ��'Q .041 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ � ' $5.00 (State Licensed Residential 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 ( )
$ 4 t) � d� Make checks payable to: City of Fridlev 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 complete and accurate; that the w�ork v✓il] be in
a�nformance with the ordinances and co o the C' of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f pe i w k s not to start without a permit on site; that the work will be in accordance with the
a�proved plan in the case of o ic e iew and approval of pla',' � ,�� �,,,%
S=GNATURE OF APPLICANT PRINT NAME /%��� ��' 41�61���i DATE�
A,PPROVAL INSPECTOR SIGN E >