P - 45473Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ",7 ' f�"� f (
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
S1TE ADDRESS � CS �v %1 r.SS, `��i � S � -
THIS APPLICANT IS: ❑ OWNER OGONTRACTOR
PROPERTY OWNER/ I NAME: ��i � n
TENANT p,DDRESS: ��C-lY�E
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
NAME: % cR
,cr�'
CITY
Permit No.: ��' �� �' I`}l`�
Received By: �
�� ' .
ATE ZIP
STATE LICENSE #_,�.f7� � G;� LEAD CERT NLIINBER
ADDRESS: 135�t� /��'crC'�Prt 'C'+r�"�' ��' �r-� CITY�Y-+�>/o J�r' STATE��IP
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRiJCTION
PERMIT TYPE ❑ �DITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE`.� ('�Z:�r, C,�-
SIZE OF IMPROVEMENT
ROOFING �
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
FAX
SIZE
STORTES
B'i�00F O DRAfN TILE
❑ SIDiNG ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
L1&BNtODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ bETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WMDOW TO BE INSTALLED NUMBER OF V
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two setz of constrvction 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)
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
$
$
$
$
$
$
$
$
$
$
$ ,%. �l D �%i
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the totat 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 Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pa�able to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERM]T-NOT VALID UNT1L 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 City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a e' 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 or �cb requires review and approval of p ! p— i
SIGNATURE OF APPLICANT PRINT NAME ��/ t.: �� C�S� DATE ���/ �� I
APPROVAL INSPECTOR SI ATU '