P - 41771�a��.�t�
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ���/�! � I
SITE ADDRESS `�
THI5 APPLICANT IS
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
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❑ OWNER
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
IU � CITY
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Permit No.:
Received By:
ATE` IaV ZIP J 3a
PHONE: (Q►d''(,Q LV" J J c�iv V
CONTRACTOR NAME:_ �cQ(,'TQ�I,YQ , �..(�,C .
SUBMIT A COPY OF �--�C
YOUR STATE LICENSE STATE LICE�NyS;E # aU J O�+aLT�L LEAD CERT NUMBER_ � �'" S I � S��n�
ANDCERTIFICATEOF ADDRESS: o'�lay �'M'L('it"l .�' I CITY r- STATEIIIP�ZIP
INSURANCE pHONE I d��� S Z g J FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCT ON SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDTI'ION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ROOF ❑ DRAIN TILE
❑ DECK SIDING ❑ OTHER
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ ADDITION
' �MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �Q � I a l3 (iG/lQS ��
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING �� ❑ HOUSE ONLY
NUMBER OF SQUARES �� ❑ HOUSE & GARAGE
GARAGES \ ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
n�vG � 1 l� 1 O� �
Vinyl
❑ Aluminum
❑ Other
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. 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 1. Site Plan/Survey showing the existing strucriues
and proposed project.
❑ Fascia 2. Two sets of construcrion 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 MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�iTCiNG THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $_ �� �� CO C1Q� 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 Pernut Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft + 6 ft = ft x$25= $ __
$450 Conservation Plan Review
Fee Detemvned 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 pernut and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and c es 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 pe' ' and wor is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of a rk whicfi qu' 'ew approval of p �� �� /`� (�' �
SIGNATURE OF APPLICANT � AME �� � l )� � DATE `�/ I� % � I
APPROVAL INSPECTOR SIGNATURE �