P - 37116u v `
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� �� `� !
SITE ADD�ss a�5
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
E�FECTNE i-1
YOUR E-MAIL ADDRESS
� 5�- ��
❑ OWNER XCONTRACTOR
PROPERTY OWNER! NAME:�
TENANT ADD�ss:
PHONE: l
CONTRACTOR
SUBMIT A COPY QF
YOUR STATE LICENSE
AND CERTIFICATE OF
IN3URANCE
PROPERTY TYPE
PERMTT TYPE
LI!'�� �[�7�1�' � 7'�
DESCRIBE WORK BEING
SIZE OF IMPKOVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
°�Vinyl
❑ Aluminum
❑ Other
NAME: 1 y t( Y�
STATE LICBNSE
ADDRESS: i.�14�
Permit No.:
. . - � : �����,;� �
. I
� . : �`�r �, ! f _ �I .1
�C�t'C�FU(1 5f� (�E _cITY �-ridl�LL� sTA�
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Z�� � EXP DATE �J�'3' I� 2-
PHONE ItG2�-7 !1 -v�llJ -- ----J____ FAX___.��.
1'8� SINGLE FAMILY/NEW CONSTRUCTION 3IZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED WINDOWS
❑ BASEMBNT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK �SIDING ❑ OTHER
❑ SWIMMING POOL
�❑ EW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODBLING
LENGTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GAKAGE
❑Soffit
❑ Trim
❑ Fascia
WIlVDOWS
IN EXISTING OPENINGS �Yes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
HEIGHT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structura] members to be used
FOIZ NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHE3 3UBMIT:
1. Site Plan(Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
IOPENING CHANGES & � I
TYPE OF WINDOW TO BE INSTALLED ��� �� NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
`d'OTAL JQB VALUATIOi\' $ Q. OCC'LTPANCY TYIPE
Permit Fee $ lp �'� �:�� See Back Page for Pee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ ! lo (.� .001 times the total job valuation
Surcharge $ �� .0005 x Permit Valuation Minimum $.50
License Surcharge $ �� $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2000 per SAC Unit (Plans to MWCC for determination)
� Curb Cut Escrow $ ft+ 6 ft= ft x$21= $
Erosion Control $ $450 Conservation Plan Review
�i Park Fee $ Fee Determined by Engineering
� Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ ..� � � '1 Make checks nayable to: City of Fridley 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 wark will be in accordance with the
approved plan in the case of all work which requires review a d approval of plans.
SIGNATURE OF APPLICANT � ^ \' �J��V"`� PRINT NAME l'I 1r�S`�' I I�.� �CL�DATE f(��'-1 ��
PLEASE NOTB: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANI_CAL WORK