P - 39910Building
Inspections
763-572-3604
763-502-4977 FAX
DATF, �' � �
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
I FFECTNE 1-1-2011
SITE ADDRESS _►!�-F ��1� l� lx l
TFIIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/ NANtE:_
TENANT ADpRESS:
CONTRACTOR
SUBMIT A COPY OP
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
�ROPEIbTY TYPE
PERMIT TYPE
TYPE OF WORK:
STATE LIC
ADDRESS:
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CER'C NUMBE
PHONE //�m� � �-� w� y � FAX
�,SINGLE FAMll_Y/NEW CONSTRUCT[ON SIZ�G _ _
❑ TWO PAMILY/N�W CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGGSHED ❑ W[NDOWS
❑ [3ASEMEN"I' FINISH l3�.ROOF ❑ DRAW TILE
❑ DI:CK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NLW HOME CONSTRUCTION ❑ AUDITION
f�MAIN"TENANCE/RFPAyR ❑ REMODELING
DESCRIBE WORK BGING DON�:
SI%E OF IMPROVEMLNT __
/�-�, �/
H F.IGH'I'
Permit No.:
Received By:
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sTa�rE/,�I/
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ROOTING � ❑ HOUSG ONLY BASEMEN7' REMODELING SUBMIT:
NUM[3ER OF SQUARES �_ �,HOUSE & GARAUL: L Existing Floor Plan
GARAGF,S �AT'I'ACHBD GARAUE 2. Proposed floor plan
PROVOSED SIZE: ❑ UGTACHED GARAGE 3. List of structural members to be used
PROPOSED IIEIGH'I':
POR NGW CONSTRUCTION INCLUDING UF.CKS,
SIDING ADDIT[ONS & PORCEIES SUBMIT:
❑ Vinyl ❑So�t I. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ "I'rim and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTWG OPENINGS �Yes ❑No LOCATION OF WINDOWS POR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DI:SCRIIIE SIZE Or MANUFAC"I'URE STICKER ON W WDOW.
OPENING CHANGES &
I TYPE OF WINDOW TO BE INSTALLED NUM[�CR OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $�����i IN� TH�997 U.B.0 FEE SCLI OCCUPANCY TYPE
�f�
Permit Fee $ j��•�� See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
� Fire Surcharge $ .001 times the total job valuation
Surcharge $ ,� .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft = ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ j�,`�, � j Make checks payable to: City of Fridley Attach Stipulations
I hereby apply for a building er
conformance with the ordina es
permit but only an applica 'on fo
approved plan in the case all
SIGNATURE OF APPLICANT
APPROVAL INSPECTOR SIGN
PLEASE NOTE: SEPARA
TH(S IS AN APPLICATION FOR A PERMIT-NOT VAL[D UNTIL PROCESSED
nit and I acknowledge that the information above is complete and accurate; that the work will be in
id codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
a permit i no to start without a rmit on ite; t at t e work will be in accordance with the
w ic r ' e e and approval of pla . �
R NT NAME DATE
rF F S F F.niJIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK