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Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
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Permit No.. ` � t� �
Received By:
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s��'E aDD�ss 7y�� �-I AY�-�� ST c�c�.�: i�.S ,E.. F� �� i r� , 1"1 s n>rv . SS� 3 Z�
THIS APPLICANT IS: 1� OWNER CICON'TRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
rrnt�: /✓r � / 1<"2,oGi t-,
ADDRESS: �4SS /i�iOYCS S� • N��=, CITY T�lDI7c STATE%yN ZIP T.r�3�
0
PHONE: 7 6 � - %��' � 9 �•
NAME:
STATE LICENSE #
CERT NUMBER
ADDRESS: CT1'Y STATE ZIP
PHONE
❑ SINGLE FAMILY/NEW CONSTRUCI'ION
❑ TWO FAMILY/NEW CONSTRUCI'ION
❑ ADDITION ❑ GARAGE/SHED
,O BASEMENT FINISH �BQtOOF
❑ DECK ❑ SIDING
❑ SWIIvIIvIlNG POOL
O NEW HOME CONSTRUCITON ❑ ADDTiTON
�MA[NTENANCE/REPAIR ❑ REMODELING
f��
o wn�rnows
❑ DRAIN TII.E
❑ OTHER
DESCRIBE WORK BEING DONE: Y► E w S60 t �.+ �I�J'
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY g,�SEMENT REMODELING SUBMIT:
NUMBER OF SQUARES � 0 HOU5E 8c GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACSED GARAGE 2. Pmposeil floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of s�rncturai members to be used
PROPOSED HEIGHT:
� FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDTCIONS_ 8c PORCHES SUBMIT:
❑ Vinyl ❑Sof6t 1. Sibe PianlSimrey s5owing the ercistmg strnctwes
❑ Aluminum O Trim
❑ Other ❑ Fascia and ProPo� t�.l�•
2. Two sets of construction plans
WINDOWS 3. Ecergy Calculations
IN EXISTING OPENiINGS ❑Yes ONo LOCAITON OF WINDOWS FOR WINDOWS - PROVIDE U-VALL7B AND
OR FOR NEW OPEIVINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION,INCLUDING THE COST OF LABOR AND MATERIALS:
(iJSING THE 199'i U.B.0 FEE 5CHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escmw
Erosion Control
Park Fee
Sewer Main Chazge
$ �� �a �- � See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �- .�1 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
$ Agceement necessary ( ) Non Necessary ( )
$ i �'1 • Make checks aavable 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 acimowledge 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 widiout a permit on site; that the work will be in accordance with the
approved plan in the case of a11 work wh' s rec�yir�s review and approval of plans. ��� � DA'I� ��L
SIGNATURE OF APPLICANT �{,�� PRINT NAME ��"! L j+ " Z d%-�
APPROVAL INSPECTOR SIGNATURE
PLkAS� NUT'�; S�PARATE PERMiTS ARE REQI7IRED F�R PLUMBING, ELECTRICAL ANU MECHAI�TICAL WORK