P - 45006Building
Inspections
763-572-3604
763-502-4977 FAX
DATF�( � (/t%/ ;�
SITE ADDRESS __��
THIS APPLICANT [S:
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-201I
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❑ OWNER �CO
NAME: `�
ADDRESS: 'fi�/ .Cc
PHONE: //�/�' � �jrQn� �
E-MAIL ADDRESS
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CITY
CONTRACTOR NAME:�r �
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: !� � CITY�
INSURANCE PHONE o�— FAX % - �
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE ��DITION ❑ ARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING O OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�vIAINTENANCE/REP�IR _ ❑ REMODELING
Permit No.:�� U� �''��"�� 1
Received By:
Dat���'d�
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A
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7�yL.STATE�%LIP,��
DESCRIBE WORK BEING DONE: /i.G�II "v�- C��L%�Ll�j
SIZE OF IMPROVEMENT LENGTH W DTH HEIGHT S FT
ROOFING ❑ OUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES '� �OUSE & GARAGE
i I. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HE[GHT:
SIDING FOR NEW CONSTRUCTION INCLUDINO DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
� Aluminum ❑ Trim 1. Site Pian/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
!i IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE ST[CKER 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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ � 5 See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ `1 .001 times the total job valuation
Surchazge $ � .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$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 �avable to: Citv of Fridlev Attach Stioulations
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 co es of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for , it d 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 all '' ' aval of p . �
SIGNATURE OF APPLICANT AME DATE�
APPROVAL INSPECTOR SIGNATU /