P - 39354Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201I
Permit No.: � � ( "� � ��G
Received By:°� r
Date� W : � �
DATE �°" �`�� YOUR E-MAIL ADDRESS `—�
SITE ADDRESS � � i�4' / �"/ R–�/;J .S�='"" .�lv �f' - �/•a--y /�? "�', ,�.�%,� %
THIS APPLICANT IS: ❑ OWNER .�ONTRACTOR
PROPERTY OWNER/ NqME: � y �' �- �r�
TENANT q�DRESS: �. j�U %1���'0 -•- .��' CITY ✓'- r a G-✓�-c, 3TATE�/LIP�
PHONE: �/.� ��'i � �/'4`/�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
NAME: /,�y %
STATE LICENSE #
.� ° ,-
LEAD CERT N
ADDRESS: c`� �' �-6 � S%'=� CT. /�—" CiTY �• /°-r� STATE �iP
PHONE C�vZ- �� S� .� 1- �� FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF [MPROVEMENT
❑ ADDITION ❑ GARAGE/SHED O WR�IDOWS
❑ BASEMENT FINISH �"ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMM(NG POOL
❑ NEW HOME CONSTRUC?ION ❑ ADDITION
❑ MAINTENANCE/REPAIR �REMODELING
ROOFING
NUMBER OF SQUARES __�
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ Aluminum
O Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ D£TACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF �
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Pian
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG 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 WTNDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED 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
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (P(ans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
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 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 work wiil be in accordance with the
approved plan in the case of all wo ic equ s review and approval of plans. ./ /
SIGNATURE OF APPLICANT � PRINT NAME ��.�e.-aGy /�s.si...DATE 9 6--' I�
APPROVAL INSPECTOR SIGNATURE �