P - 35073Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-20ll n
DATE OI�i1\
SITE AbDRE S �
THIS APPLICANT IS: ❑ O ER
PROPERTY OWNEW NAME:
TENANT ADDRESS:
PHONE: � -Iln'l
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
YOUR E-MAIL ADDRESS
Permit No.
Received By: � � ll�;�' '
�1������L 12 01
ATE�ZIP�Z
STATE LICENSE # IV^�J LEAD CERT NUMBER N�-� d�v ��
ADDRESS: 4:� �tCR.�ip'r ��Ut� CITY'�iv,�OtJ�ts �o►yy{, STA'
PHONE q5a- q IS -'7?�C� FAX Cib �1 ' �i'�� - yq9B
`� SMGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ BASEMENT FINISH �ROOF
� DECK ❑ SIDING
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDIT[ON
❑ MAINTEN CE/REPAIR REM EL:
DESCRIBE WORK BEING DONE: �
S1ZE OF IMPROVEMENT LENGTH WII
ROOFING ❑ HOUSE ONLY
NUNIBER OF SQUARES �� `�HOUSE & GARAGE
GARAGES "�CATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
S[DING
❑ Vinyl
❑ Aluminum
❑ Other
❑ DRAIN TILE
� OTHER
BASEMENT REMODELING SUBMIT:
t. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim i. Site Plan/Survey showing the existing structures
❑ Fascia and proposed projecf.
2. Two sets of construction plans
WINDOWS 3. EnergyCalculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOft NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUM$ER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:'•
1,(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
$
$
$
$
$
$
$
$
$ _ _ . .
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$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks navable to: Citv of Fridlev Attac
THIS IS AN APPLICATION 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 permit work is n t to start without a permit on site; that the work will e in accordance with the
approved plan in the case of all wor i�}r 6qv' nd approval of p s !' c- �`
SIGNATURE OF APPLICANT P T NAME �`I�I� �1�AOnIQf�"� DATE I n
APPROVAL INSPECTOR SI
PLEASE NOTE: SEPARATE PERMITS A RED FOR PLUMBING, CTRICAL AND MECHANICAL WORK