P - 40832Building
Inspections
763-572-3604
763-502-4977 FAX
DATE / � o�� � r /
SITEADDRESS /� �
THIS APPLICANT IS:
BUILllING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE; I-I-201 I
Y�O pf�j�l� � RES/
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❑ OWNER �C'ONTRACTOR
PROPERTY OWNER/ N�ME:
TENANT ADDRESS:
PHONE:
CONTRACTOR
SUBMiT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME: S � Y�
STATE LICENS6# �_
ADDRESS �'i–da�(��//C
CI'1'Y
Permit No. `� � � `�
Received By: r�'�
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.
ATE�[�ZIP�
ER"1' Nl�MI3E:R �
�% CI'1 Y _STATE,�_nZIP
PHONE ���' � �� � � �i %� f���
�31NGLE FAMILY/NEW CONSTRUCTION SILIr:_
❑ TWO FAMILY/NEW CONSTRUCTION S7�ORIGS
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING 0 O"fhIGR
❑ SWIMMING POOL
❑ NEW HOMF, CONS"fRUC'T'ION ❑ ADDI"IION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
LENGTH
❑ HOUSE ONLY
�IOUSE & GARAGE
❑ ATTACHED GARAGE
�-0ETACHED GARAGG
W
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I . E�isting Ploor Plan
2- Proposed Floor plan
3. List of svuctural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDI"T'IUNS, R PORCHES SUBMIT:
❑ Trim I. Site Plan/Survey showing the existing structures
� Fascia �nd proposed project.
2. Two sets of construction plans
WINDOWS �. tnergy Calcidations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR W WDOWS – PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRBE SIZG OF _T_ MANUFACTURE STICKER ON WINDOW.
OPENWG CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDINC THE COST OF LABOR AND MATERIALS:
(USING TNE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ ��L See Bad< Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ 1(p� .0005 x Permit Valuation Minimum $5.00
License Surcharge $ �'jb $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ � Make checks payable to:_ City of Fridley Attach Stipulations
CHIS IS AN APPLICATION FOR A PERMI"T-NOT VALII) UN'TIL PROCESSFD
1 hereby apply for a building permit and I acknowledge that the infonnation 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 1 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 ork w ich requires review and approval of plans �
SIGNATURE OF APPLICANT �_;� PRINT NAME__�/N � _DATETp� O— �l
APPROVAL INSPECTOR SIGNA—� �
'` PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK