P - 48117Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-I-20] 1
Permit No.
Received By:
�,� - � - , , , . _ ,;
DATE__�"� ��'" I I �� YOUR E-MAIL ADDRESS �� �� � N�% Z ETLO ��
S[TE ADDRESS � L.� C� i.l���C� �
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
ADDRESS: 'rJ Z'O (�i(,��� �'z- CiTY�(� STAT�APJ ZIP.
PHONE:�.,,^�.1 fj�—'L�� Cj �
N,�E: t�y �, � �c�zoru, 7a•r c
STATE LICENSE # Z QO ro �8'�i t LEAD CERT NUMBER
ADDRESS:_ {I�'�"�,�.� � �1/C . N•�%" CITY �LI�C�P�,�f� STATF���IP��fl
PHONE ��2,-��� �QZB_ FAX �Ce� �'�b�a �i��O
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
� TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK �IDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODEL(NG
DESCRIBE WORK BEING DONE:
SIZE OF [MPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
Vinyl
O Aluminum
❑ Othet
WIIVDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
TH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�Soffit
� Trim
�Fascia
LOCATION OF WINDOWS
NUMBER
'L
�
F7"
BASEMENT REMODELING SUBMIT:
1. Existing Fioor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCT[ON tNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu 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
TOTAL JOB VALUATION $�Z„� SING THE 1997 U.B.0 FEE SCHOCCU ANCY
Permit Fee
Plan Review
Fire Surcharge
Svrcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
TERIALS:
$ �s„`�jj �C � 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 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 ( )
$ (f1 Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 applicati for a r it 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 o ' h requires review and approval of pl —sy r
SIGNATURE OF APPLICANT ^^ PRINT NAME �6 �IC �h�C� DATE J�'����