P - 44210Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2010
DATE �+�O �� U YOUR E-MAIL ADDRESS
SITE ADDRESS
THIS APPLICANT I5: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT T'YPE
TYPE OF WORK:
DESCRIBE WORK BEING
�tOOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
❑ Aluminum
O Other
P�c
PHONE: 7l0 � ^ Yo? %� � �ei� o`� �
NAME: t !!a'K
STATE LICENSE #
PHONE (o/ el ^ l�Zi ` ?l le / /
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYlNEW CONSTRUCTIOII—
❑ BASEMENT FINISH
❑ DECK
POOL
❑ NEW HOME CONSTRUCTTON
❑ MAINTENANCF✓REPAIR
'�
� HOUSE ONLY
� HOUSE & GARAGE
❑ AT'I'ACHED GARAGE
❑ DETACHED GARAGE
CITY
Permit No
Received By:
D�������
A7'E�ZIP
�"7`�^kCt�"or� ��ZC.
EXP DATE
.S �� CITY �l�' G r��e STATE�ZIP .�S'6 /%
FAX
SIZE
❑ DRAIN TILE
❑ OTHER
Y' L� " 3"tG7�L° � Ptcs c� �-
HEIGHT SO FT
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2., Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION [NCLUDING 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 Calcutations
IN EXISTING OPENINGS OYes 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 WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�/ (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ arv0�, °p OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$ I'(�"! ►,;��j See Back Page for Fee Schedule ,
$ 65% of Building Permit Fee
$ _.001 times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+68= ftx$24=S
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ �— Agreement necessary ( ) Non Necessary ( )
$��"�) r!'^� Make checks [►ayable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D 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 ordinarices and codes of the City of Fridley and with the Minnesota Construction Codes; that 1 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 ofall work which requires review and approval of plans.
SIGNAIURE OF APPLICANT e,r-� ft/.�+ ce�t� �, PRINT NAME 1d/vt �i'E,�q �py �o�S7� �Il� DATE S^�O "�d