P - 41230Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20] 1
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Permit No.:
Received By:
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DATE �/�lp��� YOUR E-MAIL ADDRESS �, %o e/'f/ ��/IGSf�9'I �LL�li�C�D�iConc'aL�C7YlA/ Cdiz►
SITE ADDRESS �,,�1 � �Ga�Ly/�y/'j�ry y( �'' /(��i
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVF.MF.NT
ROOFING
PTTJMBER OF SQUARES _
GARAGES
YROPOSED SIZE:
F'ROPOSED HEIGHT:
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TATr.��( z�r SSf/'3dt
STATE LICENSE # e%Q%����� LEAD CERT NUMBER — ��� -�'
ADDRESS:�g� C'��� �j�,�� CITY� STATP��ZIP��'/()"')
RS7rZ�
Ri SINGLE FAMILY/NEW CONSTRUCTION
CI TWO FAMIL`./NEW CONSTRU:'TION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
FAX
SIZE
STORIES
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�1 MAINTENANCE/REPAIR ❑ REMODELING
i:��CL[��L !� �/'Il�'�Cl:k.�" ...L�2 PJk�s �G
LENGTH WIDTH
❑ HOUSE ONLY
_ ❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN TILE
❑ OTHER
FT
BASEMENT REMODELING SUBMIT�
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be use�
�IDING FOR NEW CONSTRUCTION INCLUD[NG L+ECKS,
❑ Vin 1 ADDITIONS. & PORCHES SUBMIT
Y ❑Soffit
❑ Aluminum ❑ Trim I. Site Plan/Survey showing theexisting structuses
❑ Other ❑ Fascia and proposed project.
2. Two sets of canstruction plans
WINDOWS 3. Energy Calculations
LV EXISTING OPENINGS �es ONo LOC�QTIQN OF WINDOWS FOR WINDOWS — PROVIDE U-VALL�E AND
OR FORNEW OPENINGS- ESCRIBE SIZE OF ,l�Pn�/'L�/�( MANUFACT'CJRE STICKER ON WIN��OW,
C�PENING CHANGES &
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)
'TOTAL JOB VALUATION
F'ermit Fee
P'lan Review
, Fire Surcharge
Surcharge
' License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ t --
$
$ b
$
$
$
$
$
$ (� f 1 �2
OCCUPANCY TYPE
See Back Pa�;e for 'Fee Schediile
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 (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Pian Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridle Attach Stipu�ations
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 v✓ill be in
conformance with the ordinances and s of the ' of Fridley and with the Minnesota Construction Codes; that I understand this is not a
p�rmit but only an application for e i is not to start without a permit on site; that the work will be in accordance vvith the
approved plan in the case of a i view and approval of pla� r�/ � �j
S=GNATURE OF APPLICANT NT NAME i�///.C� /GF��'Lt/{yj DATE �e���
A;PPROVAL INSPECTOR SIGNA � �