B - 46272Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-20] 1
DATE �-- � I— �� YO R E-MAIL ADDRESS
SITE ADDRESS _��/G �I /l/ b�e, n u 6� ,��
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: �/�,« s ,�IL /I4 M
TENANT p�DRESS: 14j/ (o �/ ,i+/ � „ �, � � CITY
PHONE:. 76 3— �S"7�/� /�� `f
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF
DESCRIBE WORK BEING
ROOFII�[G
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum�
� Other
� 1���°� s
Permit No.:..�
Received By:
Date Rec'd: ,
ATE •/y�✓`LIP 5^� '�!'���
STATE LICENSE # .2Q 5—i� / 3 G S LEAD CERT NUMBER
ADDRESS: � % �/ Q ,.,, � e � S /l�—°� /'��— CITY C7�s��,__ STATE �^�Lff' 3� �3�
PHONE 763 — ��i� �— `'/��Y FAX �
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTfON
❑ MAINTENANCE/REPAIR
WINDOWS
IN EXISTING OPEAIINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENWG CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ GARAGEiSHED � WINDOWS
❑ ROOF ❑ DRAIN TILE
�SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
D REMODELING
� /i� r�e_ .'c e,3 ��1- S �'
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
f-�J'vs,.�
SO FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. Lisf of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
L Site Plan/3urvey 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, INCL,UDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE) �
TOTAL JOB VALUATION $�, OCCUPANCY TYPE '" 1
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ pl(� � r'j�` 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 ( )
�+ 0. Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICAT]ON 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 all work �c req s review and approval of plans. /�
SIGNATURE OF APPLICANT � � � PRINT NAME J���,-�[ylc� L DATE c��� ��
�� �