P - 48339Building
Inspections
763-572-3604
763-502-4977 FAX
DATE i �� � ` �
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011 i
SITE ADDRESS J I�-I t�n�; L�^ � f �
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/ N,�tE: �
TENANT ppDRESS
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
YOUR E-MAIL ADDRESS
YBCONTRACTOR
T�f�"'��'�
Z� �}�r�' 1�1 �j �, �',�-L" c C[TY
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STATE LICENSE #�(,�� �j Z1v b�+ LEAD CERT NLIMBER
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ADDRESS: � ( ^ ' �� CITYI�t?I
PHONE �� — Fq}� � - (—
SINGLE FAMILY/NEW CONSTRUCTION SIZE )prr �.. F,
❑ TWO FAMILY/NEW CONSTRUCTION STORIES�_
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �SROOF ❑ DRAIN T]LE
❑ DECK ❑ SIDiNG ❑ OTHER
❑ SWIMMING POOL
TY.PE OF WORK: ❑ NEW HOME CONSTRUCT]ON ❑ ADDITION
i�.MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ��- �M*' �- � � �;„�C
SIZE OF IMPROVEMENT LENGTH 11-'� iC �'t' L7 WiDTH � 1 �-2 I� HEIGHT
ROOFING � � ❑ HOUSE ONLY
NUMBER OF SQUARES �3.HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: -�DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
❑ Vinyl ❑Soffit
❑ Aluminum ❑ Trim
❑ Other ❑ Fascia
WINDOWS
iN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE RJSTALLED NUMBER OF WINDOWS
Permit No.: �
Received By:_
Date Rec' d: �
TATEf�P �Z]P
A
FT ��"'��
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION �NCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT
l. Site Plan/Survey 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 N'�;�;5 AK�; BASEll 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 Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �,� j See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �] .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ � f (_` $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 ( )
$ � , J� Make checks aavable to: Citv of Fridlev Attach
ulations
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 ordinance ° od of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application mit 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 � �hich r uires review and approval of plans^�'��' � �l � "`� _'') .� ��
SIGNATURE OF APPLICANT � PRINT NAME -� 1��i DATE
APPROVAL INSPECTOR SIGNAT E "'�
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