P - 47962Building BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTrvE �-i-ZOi t
DATE C�� ` YOUR E-MAfL ADDRESS � t\o�iJ� ,�� � 7,
s►TE a��xess ( �cS�Y� ��t�J {"t7 � ,`">�° � �...i� ,i�a tr'Y��
THIS APPLICANT IS:
PROPERTY OWNER/
TENAIVT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
❑ OWNER bCONTRACTOR
NAME:
�
CITY
NAME: L �'�. i.G�i��-�. I .�'i'`lJ� ,'�J� (��\ �.i�.- �� �
STATE LICENSE # 4� ���� ��� � LEAD CERT NUMBER
ADDRESS: �� C(j���_� C.� i S�ts-C� �J �� • CITY �Gj=
PHONE_�!i��J`°'�5,�"'�'S��-V FAX � (p '°°;
�INGLE FAMILY/NEW CONSTRUCTION S[ZE
❑ TWO FAMILY(NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �'kFOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
_ ❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�'1GIAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � PIa �.�,,y✓'�.,���','Tor1 1�rc�(>.��
SIZE OF IMPROVEMENT '% � �1� LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �(� ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ V inyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
Permit No.: '`��
Received By:
� �- � _ ; ; �
v-�
STATE�ZIP��
A'
FT
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDING DECKS,
❑Soffit ADDITIONS_ & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No 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 WINDOWS
ALL FEES ARE BASED ON VALUATIQN, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ [(`1' ,�� 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
$ �i1.Z.'i
$
$ (,;, r
$ �
$
$
$
$
$
$
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 pavable to: Citv of Fridlev
Attach Stipulations
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 pian in the case of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT=���� �' C--r_,_�-- PRINT NAME �'1�'�'yZ (� �irz--�- DATE (�—i— L�
APPROVAL 1NSPECTOR SIGNATURE