P - 44533Building
Inspections
763-572-3604
763 -S 02-4977 FAX
DATE �% '��'/ `
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MA][, ADDRESS ��
SITE ADDRESS l,.i�-- �a�6d f�iS'S��S.r/���i� S�' /`✓F�
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
L
Permit No.:
Received By:
�': '-r, ��� ,
., � , . � �
C on�, G s� .r� . ev�T
ADDRESS: �o� SO /`N J SS�� S1 � pA/ ST �E CITY Y—/ /�lE.'y STATE h'� ZIP
PHONE: ��%'o�-9S= �Jv�-foL
N,4n�E: Sv�v�b aw► h��e ��om�/�y9-
STATE LICENSE #��6 3�7S y'r) LEAD CERT NUMBER
ADDRESS: /z! �e �4� CtTY L/� CQ�nq STATE�Z(P S�S/I
PHONE �OS%—�. �' j-7(o11 FA.X �,�%— �%QO '.3.'7-�-/ �
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
I�TWO FAMILY/NEW CONSTRUCTION STORIES �
PERMIT TYPE I ❑ �DITION
O BASEMENT FINISH
❑ DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
" dCiMAINTENANCE/REPAIR
DESCRIBE WORK BEtNG DONE: �T��i!•
S[ZE OF (MPROVEMENT
ROOFING �C�
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SID�IVG
❑ Vinyl
❑ Aiuminum
❑ Other
❑ GARAGE/SHED ❑ WINDOWS
�OOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
O ADDITION
❑ REMODELING
� HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED 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 �
WIDTH
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor pfan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structureg
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — 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)
AL 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
.00OS 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 Plan Review
Fee Determined by Bngineering
Agreement necessary ( ) Non Necessary ( }
Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROC6SSED
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 or 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 all rk ich eq ' es review and approval of plaqj� 'J
SlGNATURE OF APPLICANT PRINT NAME J� �J �P� Z E���S DATE !� ZO'� � I