P - 47785Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2011
DATE � --/�/ "/� YOUR E-MAIL ADDRESS
SITE ADDRESS � �;, , � j� j�,� ���"..
THIS APPLICANT IS: ❑ OWNER l9EONTRACTnu
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
ADDRESS: CITY
PHONE:
Permit No.: �4��l�iS�� (
Received�By���{'��U '
�e�e�'� �v � �
ATE ZIP
NAME:��11�' 'vc.f�-�%1 ( � ii r.
STATE LICENSE #��U�j4,; � LEAD CERT NUMBER�,y:}'j l���,_ �
ADDRESS: ��.?j � • t'" ': '— ' �{�l;� CITY " STATE/�� vZIP .r>�
PHONE �`S -- �(}C? ' (v.�Y� FAX
CFSWGLE FAMILYMEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT F[N[SH
❑ DECK
❑ NEW HOME CONSTRUCTION
�OOF
❑ SIDING
SIZE
STORIES
�/SHED ❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
NG POOL
❑ ADDITION
❑ REMODELING
DESCRIBE WORK BEING DONE: � ���
SIZE OF iMPROVEMENT LENGTH WIDTH
HEIGHT S FT
ROOFING c. ❑ HOUSE ONLY
NUMBER OF SQUARES J r• ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT•
GARAGES ❑ ATTACHED GARAGE �• Existing Floor Plan
PROPOSED SIZE: ❑ DETACHED GARAGE Z• Proposed floor plan
PROPOSED HEIGHT: _ 3. List of structural members to be used
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑Soffit
❑ Trim
❑ Fascia
�� FOR NEW CONSTRUCTION INCLUDfNG DECKS,
V�� ADDITIONS & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
WINDOWS Z. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS 3• Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROVIDE U-VALUE AND
OPENING CHAIJGES & MANUFACTURE STICKER ON WINDOW.
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 $ OCCUPANCY TVPF
' Permit Fee �`�`
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
_ a b S�vJ 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• Citv nf Frirl1ey Attach
.
THiS IS AN APPLICATION 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
pernut 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 of 1 0 ' uires review and approval of pl s.
SIGNATURE OF APPLICANT '( "� � PRINT NAME ,/�j y -
APPROVAL INSPECTOR SIGN U E �� � � DATE �:%�,