P - 44230Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 7-1-2010
DATE� �� �� /C/ �OUI� E-MAIL ADDRESS
SITE ADDRESS �Gf 73 �-'�7' ��.� G%E'
THIS APPLICANT IS: ❑ OWNER �7(�,ONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
Permit No..4'� ��'
Received By:' ' - �
D�����' � � � ° p
ADDRESS: 7y � 3 G�E 3�— �/�G�� CITY F7'._� STATE %t�G( ZIP S J� 3
PHONE: ? � j �_2 7-^ �� �
NAME: � x'Ti��� ��
STATE LICENSE # �`J� �c� �� EXP DATE — � l `- % �
ADDRESS: �(o�� /'���'t.r�t ST� CITY���STAT �ZIP ,�G
PHONE ��2 ` �� — g�7� FAX
'SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
O DECK � SIDING O OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � JAf.l� i��G!i'�'
SIZE OF IMPROVEMENT LENGTH %G WIDTH /S HEIGHT �'i / S Ff
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Pian
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
�FOR NEW CONSTRUCTION INCLUDING DECKS,
Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
O Aluminutn ❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed pmject.
❑ Other � Fascia ` 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS ����� �-- FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF /���' "ri'� MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &c
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
SING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION $��"J� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Emsion Control
Park Fee
' Sewer Main Chazge
� Total Due
$ `,7y' See Back Page for Fee Schedule
$ �— 65% of Building Permit Fee
$��i .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ �'� $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+68= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ ���� Agreement necessary ( ) NonNecessary ( )
$ ���o( J Make checks pa_yable to: City of Fridle_y Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL(D UNTIL 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 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 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 �1`3' rk es review and approval of plan`sA. + ^-�'7 //�
SIGNATURE OF APPLICANT if.%���^� PRINT NAME �'/(� ��� DATE !�� ( v
APPROVAL INSPECTOR SIGNATL3