P - 45276Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE I-1-20] 1
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DATE_ /�,����p�VI� YOUR E-MAIL ADDRESS �rI"l�.l�/^�e�,,,� `'t /�bey�cC�(JS /""�'�"u,Ctl-'a' a Gcs�/•ti
S[TE ADDRESS �_ jC te (77 sc �/^( �%C L�
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/
TENANT
NAME:��y,� (sSH.r�.�t
ADDRESS: �(�2C7 y2+c-G- ��-� �'�� CITY .�r+�\�V STATE ZIP,
PHONE: R7U2�"��,3�„�"—r�G� %Z—
CONTRACTOR N,�E:_ _�.,�.� � �,
SUBMIT A COPY OF STATE LICENSE # Y 3� �
YOUR STATE LICENSE ��P 1-s �� LEAD CERT NLIMBER
AND CERTIFICATE OF ADDRESS: �� ZZ ZG � �4��. H�� CITY �.r+ ��•^STAT�IZIP���I Z
INSURANCE PHONE lo�� vZgi^ �� % � FAX �s�I �G��3 -"'�%�7 �
PROPERTY TYPE
PERMIT TYPE
�NGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH OOF
❑ DECK ❑ 1DING
❑ SWIMMING POOL
SIZE
STORIES
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODEL)NG
DESCRIBE WORK BEING DONE: ,�� " ��o�
SIZE OF [MPROVEMENT LENGTH WIDTH
ROOFING ❑ OUSE ONLY
NUMBER OF SQUARES �_ �iOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ A(uminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANG�S &
TYPE OF WINDOW TO BE INSTALLED
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
❑ WINDOWS
❑ DRAIN TfLE
❑ OTHER
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION �NCLUDiNG DECKS,
ADDITIONS. Bc PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction 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
$ �,"l.L�
$
$
$ �Q
$ �b
$
$
$
$
$
$ ,
See Back Page for Fee Schedule
65% of Building Permit Fee
.00I 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 of Fridlev Attach
THIS IS AN APPL[CATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and c s of the City of Fridley and with The Minnesota Construction Codes; that I understand this is not a
permit but only an application e it 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 w ch requires review and approval of pla /�/�
S[GNATURE OF APPLICAN PRINT NAME DATE !/
APPROVAL INSPECTOR SIGNATUR