P - 39774Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ` � i�^— ��
SITE ADDRESS C? 1�
THIS APPL[CANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLE�
EFFECTiVE t-1-2011
R E-
w
❑ OWNER �CONTRACTOR
PROPERTY OWNER/ l NAME:
TENANT I . ��...
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF [MPROVEMENT
~ �- �f ..Sf
Permit No.: 2v
Received By:_
Date Rec'd: c1
� 19� 1'1�1 �� l b rtl � Co
� �L� ' STATE ZIP
��
l�
NAME: �� J � i�> (� YV .s 'V'� r Y✓ 'f L� J W d` 1� f� 6�
STATE UCENSE # � � LEAD CERT NUMBER
ADDRESS: cJ S�{ ( ( a��•1�=5 S+T— CiTY � G./ `��S . STAT�W ZIP���- (
PHONE %(�� % S'f � � � 'Z 2�1� FAX �I %� - � � `��LI � �r' Ssy
�SINGLE FAMILY/NEW CONSTRUCT]ON SIZE
O TWO FAMILY/NEW CONSTRUCTION STORIES 2,_
❑ ADDITION D GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �,ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR C� REMODELING A „ r1
ROOFING ' �J
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
i. Site Plan/Survey showing the existing structures
and propased project.
2. Two seis 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:
G THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ 2 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
$ �
$
$ .�
$ �,
$--T�j , �L�
$
$
$
$
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 oavable to: Citv of Fridlev Attach
lations
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 p�'rm�t' and ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of la l�ork which r r s review and approval of pian . � Q�
SIGNATURE OF APPLICANT �{''G����1ti+x.S PRINT NAME �y1( }� S J,�M �A �1 DI�ATE 1�� "� (
APPROVAL INSPECTOR SIGNATURE