P - 45377Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-20] 1
DATE
SITE ADDRESS � ��� � �-�J�Z'J-"�
THIS APPLICANT IS: �'OWNER
YOUR E-MAIL ADDRESS
Y� �'
❑CONTRACTOR
Permit No.:
Received By:
Date Rec'd:
�� -�� C �-v�,�, ��
1 i ��
PROPERTY OWNER/ N,qME: j-'��;,ts�Lp l-��'�
TENANT �, , J � 2 rJ� � �
ADDRESS: �� 4��-° CITY `��� l�'-' STATE� � ZIP -�`,�3�
PHONE��� Z, '�J��3 `� S �-'�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
1NSUR.ANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFTNG
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
STATE LICENSE # LEAD CERT NLIMBER
ADDRESS:
PHONE
C��•1
fz3:SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
� BASEMENT FINISH �ROOF ❑ DRAM TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SW[MMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
SIDING
❑ v�„y► .Z � ��`z
❑ Aluminum
❑ Otfier
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑so�t
❑ Trim
❑ Fascia
LOCATION OF WiNDOWS
NUMBER OF
HEIGHT
STATE ZIP.
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDING DECKS,
ADDITIONS, & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR W[NDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
U ING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ �a ��Cp 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
$
$ , —
$ I �i
$ '� c c�
$
$
$
$
$ _ � z��--
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: City of Fridlev Attach Stiuulations
`�THIS IS APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building �t d I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinan s , c des the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio for a e it d 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 a 1 work 1� �i r quires review and approval of �1�j�j�,�, (
.SIGNATURE OF APPLICANT t PRINT NAME�'tP►�L.s�>�t� lQ�o� DATE L�i - f� �- 20 ��(
APPROVAL INSPECTOR SIGNATURE