P - 35407Building
Inspections
763-572-3604
763-502-4977 FAX
ne� � � S � �
SITE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
r.
YOUR E-MAIL ADDRESS
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: I �
TENANT ..,..,.r,,,. �t�n �7f,.n r/�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERNIIT TYPE
TYPE OF WORK:
STATE LICENSE # L��
ADDRESS:7�P1� W�I�iJ1�1n
rxorrE ,� t� � " "1 �, — � � 7 1
�9`INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FIAIISH R'�tROOF
❑ DECK 0 SIDING
❑ NEW HOME CONSTRUCTION
� MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
Permit No.:
Received By:_
Date Rec'd: �
� 1�+ C CIT'Y I
���.YuC�h
LEAD CERT NUMBER � � `
� � S}Q . j-FZ 'Z2� CITY � in
� FAX�V/� -I�l� � '
SIZE
STORIES
JSHED 0 WINDOWS
❑ DRAIN TII,E
❑ OTf�R
NG POOL
❑ ADDTI'ION
❑ REMODELING
WIDTH HEIGHT
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F°I'
ROOFING �� ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES @�I30USE & GARAGE l. Eacisting Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl OSoffit ADDIIIONS_ c@ PORCHES SUBMIT:
❑ Aluminum ❑ T� 1. Site Plen/Survey showing the enisting structures
❑ O�er ❑ Fascia and proposed project.
2. Two sets of constructiai plans
WINDOWS 3. Energy Calculations
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 TFIE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
iOTAL 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
$ �{�5 See Back Page for Fee Schedule ..� Q� b'� ,� D
$ 65% of Building Petmit Fee
$ � .001 times the total job valuation
$ .0005 x Pern►it 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 ( )
$ , o Make checks aavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN11L PROCESSED
I hereby apply for a building permit and I aclrnowledge that the information above is complete and accurate; that the work will be in
conformance wit}i the ordinances and codes of the City o ridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a pernrit an ork i ot to start without a permit on site; that the work will be in accordance with the
approved plan in the case of k i re' w and approval of pl �y��,�n � 2S" ��
SIGNATURE OF APPLICANT P�1T NAME �� S I�i W 11 W�C. DATE
APPROVAL INSPECTOR SIGNATURE l�%�