P - 39571Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE_ �'�v�- C( • 1% YOUR E-MAIL ADDRESS
SITE ADDRESS �i,L�i��J` �(,�,�r-C�. S� N G
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
C►��i�
�
Permit No� � � `-'a� ��
Received By:
Date Rec'd:
ADDRESS: (,� `ti�� �'�u„L�_��- j�7 i�� CITY � �c3 � STATE��?ZIP �'3�S�Z.
PHONE: '� (n � �^ �S '7 � ' f Z v�
NANIE: �-�w�-e. {Z:�--� ZC )�dc-'+zo�•�
STATE LICENSE # � 1C�(� 3G<<f,�� LEAD CERT NLiMBER
ADDRESS: ;Z vC:. �'t' �` C,�- �. (C�v� t��i} c� CITY �,�1uGK�.-• �\ STATE�ZIP S SC' [�
PHONE . `Z C.% 3 ~ 4'4 �( —��,R' � FAX 7fe� -'f3Y� �i�(�!7
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ �DITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: �❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DBSCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES L �lG
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
Q Vinyl
❑ Aluminum
❑ Other
W INDOW S
IN EXIST[NG OPENTNGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
SIZE
STORIES /
�R,QOF [7 DRAIN TILE
❑ SIDING ❑ OTHER
Cl SWIMMING POOL
❑ ADDITION
❑ REMODELING
�DUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACH6D GARAGE
❑ DETACHED GARAGE
OSoffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HBIGHT
FT
BASEMENT REMODELING SUBMIT:
1. �xisting Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCT-IES SUBMIT:
i. Site Pian/Survey showing the existing structures
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, INCLUDI1vG THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ JXr �'`'� �ZZ� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
I SAC Charge
Curb Cut Escrow
� Erosion Control
! Park Fee
! Sewer Main Charge
Total Due
$ �� . Z�
$ �
$ . o
$
$ �5 . ��-
$
$
$
$
$
$ .
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 aavable to: Citv of Fridlev
Attach Stinulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 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 perm an ork is not to start without a permit on site; that the work wili be in accordance with the
approved plan in the case o wor whi r 'r s review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME "��,u..c. ��•'s Ic�( DATE g" Z�/' �(
APPROVAL INSPECTOR SIGNA