P - 84276Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2010
Permit No.
Received By:
Date Rec'd:
DATE %��' Z✓` C L YOUR E-MAIL ADDRESS � f�1 P1 �-O..p UT I� S\� �� �� ��1 � C1"� W t�. C-6 �'�
SrrE a,�DRESS i(D I(j 1 C„E.,. CIZ��� �
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ I N�:�
TENANT ,,�Dx�ss:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
��T
�
NAME: I/��.L,! �C.'��C3� f-f i
STATE LICENSE #_ � `�(-L
ADDRE3S:3 � OG���Z.�
PHO�q �2- cr�
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH '�ROOF
❑ DECK ❑ SIDING
❑ SWIMMINGPOOL
_ci� F2� +�c,!� l�
�P2ov�M�n�
EXP DATE i
CITY� ?�f,i
F� R5z-�33 -
SIZE
STORIES
❑ WINDOWS
p DRAIN TILE
� OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ' �
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING �J � HOUSE ONLY
NUMBER OF SQUARES iC,,.� `f�HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vin I ADDTTIONS. & PORCHES SUBMIT:
Y ❑ Trimt 1. Site Plan/Survey showing the existing structures
❑ Aluminum
❑ Other ❑ Fascia and proposed project.
2. Two sets of conshucrion plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALtTE 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:
ING THE 1997 U.B.0 FEE SCAEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ ; S 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 $.50
License Surcharge $ �(� $5.00 (State Licensed Residential ContractArs)
SAC Chazge $ $2100 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft.x $22 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
' Total Due $ ., Make checks payable to: City of Fridlev Attac
THIS IS AN APPLICAITON FOR A PERMIT-NOT VALID UNTIL 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 with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a pernvt d 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 all w k whic equires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME��I� �T�DATE �� ��' �
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