P - 35121Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-I-2011
DATE YOUR E-MAIL ADDRESS
SITE ADDRESS `I, V � �j� G �'L
THIS APPL[CANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
❑ OWNER
NAME: �
ADDRESS:
PHONE:
NAME:
STATE LICEN E
�CONTRACTOR
1l.
CITY
Permit No. �
Received By:
�
Da � � 'd� �
TATE 4v1.(JZIP
LEAD CERT NUMBER
,�� CTTY 'L E L� STAT P !V
— 2 3 ��lo'�i °%' `� F,ax
PROPERTY TYPE ❑ SINGLE FAMILYMEW CONSTRUCTION � SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑�DDITION q GARAGE/SHED ❑ wtt�lDOw5
❑ BASEMENT FINISH � &OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINT�NANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
ROOFING
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
❑ Other
; WINDOWS
; IN EXISTING OPENINGS ❑Yes ❑No
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
� OPENING CHANGES &
� TYPE OF WINDOW TO BE INSTALLED
i LENGTH
J
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
HEIGHT
f�
BASEMENT REMODELING SUBMIT:
L Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT[ON INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
L Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of consuuction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
���.
��%
/►
���:r,
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times tYie total job valuation
.0005 x Permit Vatuation 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 payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowle e that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes th C' of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f pe is not to start without a permit s' e; that the work will be in accordance with the
approved plan in the case of a w s review and approval of pl / � //'
S[GNATURE OF APPLICANT PR[NT NAME Gt� � DATE 7�! '°//
APPROVAL 1NSPECTOR SIGNA