P - 45717Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2011
Permit No:��� � ����
Received By: ��,
!� . ' " �: � i
DATE ��L( Z�/�Z �I/ _ YOUR E-MAIL ADDi2ESS ��:�I.�r�(/V,e/4tJl� 4} C�/?�!/"F IL •�Cp1°I/(
SITE ADDRESS ��yC% NE 2� 5�• F)� ( a(, C'i �/V\ hS
THIS APPLICANT [S: � OWNER ,�ONTRACTOR
PROPERTY OWNER/ N,4ME: ����� � � L��
TENANT p,�DRESS: `lS�Ib J�� �`I�� CITY F2�pLEti STATE�ZIP
PHONE: �7(p �j `J�] Z ("J (?�'
CONTRACTOR Natv1E:_ 2 prC.�.1 WE ► N,�►4 c�
SUBMIT A COPY OF STATE LICENSE # ZD (c� ��C+2-K LEAD CERT NUMBER
YOUR STATE LICENSE
ANDC�RTIFICATEOF ADDRESS:�(jS `7�OT"� p�i� � CITY CC1L. 1-FjS STATE1rtNZIP55`i�1-1
INSURANCE pHONE 5 I % Ii ►`i FAX '—
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION S[ZE
❑ TWO FAMILY/NEW CONSTRUCTION STOR[ES 2
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
�,MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �..E - ROO� � 5il7�Nf� /�%�GE %�Ff°Lft-Cf�hC�CP055/�3CE�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING �HOUSE ONLY
NUMBER OF SQUARES �l� • e� 2 ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING
V inyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISi'ING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING C�[ANGES &
TYPE OF WINDOW TO BE INSTALLED
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
FOR NEW CONSTRUCT[ON fNCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. 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:
(USING HE 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
$ �3,�-S
$
$
$ l
� s�
$
$
$
$
$
$ � � '� �3
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 navable to: Citv of Fridlev
Attach Stipulations
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 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 wo k is not to start without a permit on site; that the work will be in accordance with the
approved ptan in the case of r w i req ' review and approval of ians.
SIGNATURE OF APPLICANT T PRINT NAME�S�-CQ �NI��I��� DATE lD I27 � ZD 1 I