P - 48486Building
Inspections
763-572-3604
763-502-4977 FAX
UILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE �'��� I Z Z �� I YOUR E-MAIL ADDRESS
SITE ADDRESS 9� I (� �� i� (� �eP IC 7�C��1`6�P �Y; �G � y�
J
THIS APPLICANT IS: ❑ OWNER `�CONTRACTOR
PROPERTY OWNER/ N,�v1E: wh (G � •CY'�'�' ,SwaHalv��'
TENANT ,qDDRESS: / � [ f (� le
PHONE: '�"
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSFD SIZE:
PROPOS�D HEIGHT:
SIDIN �
❑ Vitiyl
❑ Aluminum
❑ Other
STATE LICE� # V,S L(p �`
ADDRESS:_ < U, `� ZZZ;
PHONE "'��3 %,j 2 �
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
Permit N
Received By:
Date Rec'd:
ATE ZIP
,�
CERT NUMBER
CITY �r� I.0 �� STATE�ZIP �3 //
FAx 63 GtzS Ia6K
SIZE
STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
�DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
E: /% x 1.6 �l.c.
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
O HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
WIDTH /� HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. 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:
(U ING HE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ "2 1 C� F� 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
$ � i� • GS
$ ��'• � �
$ a Qd
$ •�t0
$
$
$
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 of Fridlev
Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I�c owledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of th City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a it and ork i 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 hi require re ew and approval of p �/ � Z 1�
SIGNATURE OF APPLICANT i, PRMT NAME �G/�,a' ��InY+ h,-✓� DATE �
APPROVAL INSPECTOR SIGNATU !�
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