P - 43813Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2010
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DATE S` �') '" � V YOUR E-MAIL ADDRESS C-�^r. S���C (z+f �% � �,�,� ��,� ��,t.
SITE ADDRESS _S�. 3� F: � I"'`�'` �- S`C C%� �- c\\ �,� vy�,,,p�
THIS APPLICANT IS: �WNER ❑CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
NAME: C i�t�i S �D(r Fe�'
ADDRESS: �Z�j � F � `\ �`"`" �— j -C CITY
PHONE: 6 I Z ^ � 2 �2. ^ � �j �j �
STATE LICENSE #
!';c�1�
EXP DATE
ADDRESS: CITY
PHONE FAX
{�'SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTION STORIES
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
,�MAINTENANCFJREPAIIt
DESCRIBE WORK BEING DONE: �C. R-ao�.
ROUFING
NUMBER OF SQUARES �
�ARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
wnvnows
IN EXISTING OPENINGS ❑Yes �No
OR FOR 1dEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ GARAGE/SHED ❑ WINDOWS
�+ROOF ❑ DRAIN TiLE
� SIDING 0 OTHER
O SW[MM1NG POOL
❑ ADDITION
❑ REMODELING
O HOUSE ONLY
❑ HOUSE & GARAGE
�A17ACHED GARAGE
❑ DETACHED GARAGE
�Soffit
❑ Trim
❑ Fascia
LACAT/ON OF WINDOWS
NUMBER OF
TEn'1�ZIP S�y�
'ATE ZIP
FI'
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. 8c PORCHES SLJBMIT:
1. Sitc Plan/Survcy 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)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Swcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$
$
$ ��SS
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$2100 per SA� Unit (Plans to MWCC for determination)
ft+68= ftx$24=�
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: Citv 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 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 wo k wh' h requires review and approval of plans.
SIGNATURE OF APPLICANT �� � � PRINT NAME l. l�(�� S C'1� o FFe� DATE -� �� I v