P - 37256Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFPECTIVE 1-I-2011
DATE � � /d " -���� YOUR E-MAIL ADDRESS
SITE ADDRESS Sc1� _S�Ga GZS��,�.,c�p,.� S1�r".er� i/V� ��,
_�_
THIS APPLiCANT IS: ❑ OWNER ��NTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME:
PHONE: rp%� — ��Q�_�7D s'�
n
Permit No.: �- �
Received By: ��"�
Date Rec'd: �� ��' � (
STATE�ZiP.SS -��
NAME:�igJ�GG'f�et /���t/�-�
STATE LICENSE # 5,.� Se� LEAb CERT NLIMBER ,�� �I�O %� -� %
ADDRESS: I�7.S�S'' �Ea .�� �� CiTY � , /t/ ��t STATF/�ca/ Z[P�
PHONE ,�"o � �'�7 3 —� �G'l % FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDTTION ❑ GARAGE/SHED
❑ BASEMENT FINISH �OOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODEL[NG
DESCRIBE WORK BEING DONE:
ROOFING
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WiNDOW TO BE INSTALLED
/ -
�1-10USE ONLY
�`NOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF W[NDOWS
OF
❑ DRAIN TILE
❑ OTHER
's�-�.o ✓/ir--�
HEIGHT SO FT
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADD[TIONS & 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: /O �60
(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
Totat Due
$
$ �
$
$ � iz�—
$
$
$
$
$
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 payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work wi(1 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 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 of all c w �i�E qu' 6 view and approval of pla ._ / ry
SIGNATURE OF APPLICANT -- PRINT NAME����S��6lc�✓' DATE a_/��o�%��
APPROVAL INSPECTOR SIGN T E