P - 35080Building BUILDING Pernut No.: � �% ���-
Inspections RESIDENTIAL APPLICATION Receivect sy:�ti1C{�_—
763-s�2-3604 CITY CiF FRIDLEY �a '
763-502-4977 FAX EFFECTiv� i-i-aoii �C�e� �����
DATE '�'�1'� �( YOUR E- L AD RESS
SITE AD RESS � � � � L � � � `�L � ��
THIS PLICANT IS: �OWNER OCONTRACTOR
PROPERTY OWNER/ ? N�: ` � , ti
TENANT ��nttESS: � N\ ,� t STnTE��r G `
= PHONE: ���� " ����� �O�
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAb CERT NiJMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADURESS: CITY STATE ZIP
INSURANCE pHONE FAX
PROPERTY TYPE j'l�INGLE FAMILY/NEW CONSTRUCTION SIZ�
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERNIIT TYPE ��DIT'ION ❑ GARAGE/SHED O WINDOWS
❑ BASBMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK SIDING ❑ OTF�R
O SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR 0 REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �� ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
i . Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed 800r plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of smcctural members to be use�
PROPOSBD HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS_ 8t PORCHES SUB�VI��
❑ Viiryl �Soffit 1. Site Plan/Survey showing ihe e�tistin� �dures
❑ Alutninum ❑ Trim
❑ Other ❑ Fascia �d ProP�� I�l�-
2. Two �ts ofconstruction plans
R+�IDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes ONo LOCATION OF WINDOWS FOR WINDUWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE STZE OF MANUFACTURE STICKER ON WINDOW.
OPENII�iG CHANGES �
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASEll (JN VALUATlON, llVC;LUDIN(i THE CUST OF LA13UR AlVll MATE1t1AL�:
(USING THE 1997 U.B.0 FEE SCHEDiTLE)
TdTAL JOB VALUATION $ OCCUPANCY TYPE
Permit F�
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Girt Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$_�� ���Z_____ See Back Page for Fee 5chedule
$ 65% of Building Permit Fee
$ _ .00I times �e total job valuation
$ `L. .4005 x Permit Valuation Minimum $5.00
$ $S.QO (State Licensed Reside�tial Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25—$
$ $4S0 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � Make checks aavable to: Ciri of Fridlev Attac6
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID IJNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordir�ances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit bnt only an application for a permit 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 o� al w c review and approval of p'���� �� �/' !/�
SIGNAI'URE OF APPLICANT ��� PRINT NAME a� ��� DATE '7 '
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