P - 45302Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-20] 1
Permit No.: �( � `�
Received By:_
Date Rec'd: �
DATE %�+Zi� I� ` r YOUR E-MAIL ADDIZESS ��V9 i�`/ `�'F �-t ���G✓(�j/_( �( zC � 6�✓M
S►TE ADDR�� V ,� ���l' ) S� i�I"� � VY fli � /)%
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NqME
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
PHONE: /f7 -Z '
NAME: M t��f� �
STATE LICENSE/ #_
ADDRESS: t.'�1"�
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ATE
LEAD C:ERT NUMBER �Y,�% j�Ci,3 �f.f -- l
CITY 0��� � °�y?iV�TATE�ZIP ��jG`r l/%
PHONE �,�?'' �Z7' ��i�P� FAX (j`3-5�,
a� s
❑ SINGLE FAMILY/NEW CONSTRUCT]ON S1ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
C] BASEMENT FTNiSH f ROOF ❑ DRATN TILE
❑ DECK ❑ SlDiNG ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
■ MAINTENANCE/REPAIR ❑ REMODELING
_. ��(i^(' (',-nr� I'a — ��9° �-. � ,°7 , % f"
ROOFING
NUMBER OP SQUARES � �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
O Other
r
�. �,��5e � )G,�'�-���
TH WIDTH HEIGHT
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
FT
BASEMENT REMODELING SUBMIT:
1. Exis[ing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Fascia 2. Two seu of construction plans
WINDOWS 3. Energy Calculations
[N EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDQWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ ��i j� �p �► -r'j � 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
$
$ p -
$ 3 /
$
$
$,
$
$
$
$ � .
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 (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks qavable to: Citv of Fridley Attach
lations
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 will be in accordance with the
approved plan in the case of all work wh� review a roval of plans.
SIGNATURE OF APPLICANT E?„��Y� �,� � _ RINT NAME '%7��rM ✓V! � � DATE ����I
APPROVAL INSPECTOR S[GNA � C T
2 � �-�