P - 35093Building
Inspections
763-572-3604
763-502-4977 FA�
DATE ! '�"��
SITE ADDRESS S La
BUILDING Gl � , �'
RESIDENTIAL APPLICATION
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/ NAME: �
TENANT ADDRESS: �J
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CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
CITY OF FRIDLEY
EFFECTIVE 1-I-201 ]
YOU E-MAIL ADDRESS
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�ONTRACTOR
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STATE LICENSE # � ?
fONE Lo,S �-- �%cy �-[-� �.�y Y' lp
SINGLE FAMILY N
TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION O GARAG
❑ BASEMENT FINISH �0'1FOOF
❑ DECK � SIDING
�l
SIZE OF IMPROVEMENT
R OFING
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
O Vinyl
❑ Aluminum
❑ Other
Permit NQ.:
Received By.
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, �,_ �
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1
LEAD CERT NUMBE '`+
J�-P CIT /�,�QSTAT�IV��Q�
FAX c.Pa I"' 7 O�"�d S�
SIZE
STORIES
HOME CONSTRUCTION ❑ ADDITION
ITENANC /REPAIR ❑ ODEL
C � �,
H WII
D HOUSE ONLY
� HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
BASEMENT REMOAELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDI7'IONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Fascia 2, Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-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:
(U�iG TH�1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ G� � OCCUPANCY TYPE
Permit Fee • $ See Back Page for Fee Schedule
Plan Review $ _ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $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$24 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ �-�-- Agreement necessary O Non Necessary O
Total Due $ J�I !77. Make checks navable to: Citv of Fridlev Attach Stinulations
THIS IS AN APPLICATION FOA A PERMIT-NOT VALID UN7'IL PROCESSED
I hereby apply for a building permit and 1 acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the Ci of Fridley and with the Minnesota Construction Codes; tfiat I understand this is not a
permit but only an applic on or a permit and o is not to start without a permit on site• that the work will be in accordance with the
approved plan in the case o Il ork vyhi e ui v' w and approval of plar�s. �� �. /(.,�,, ��
S I G N A T U R E O F A P P L I C A N T �i(� P R I NT NA M E �J D AT E
APPROVAL INSPECTOR SIGNAN