P - 35079Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS _
TH[S APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATI4N
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
.3 / �3 r� ��''
❑ OWNER
YOUR E-MAIL ADDIZESS
PROPERTY OWNER/ NAME: �� l.°r. ���s� --
TENANT qDDRESS: S S� 3/ �3�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
PHONE; _ _ 76 ,�— �' 7r — �S / �
..,� s .
CITY
%
Permit No.:
Received B �:
Da�R��' d� U �... . � � � � �
ATE � "'2IP �'s ����'Z
STATE LICENSE # �ct .S"� /3 G.S� LEAD CERT NUMBER
ADDRESS: �5'7Zr� Q�, e�.•S ..��.� /�� C(TY 07t.SQ.� a STATE •��P S�s� �
PHONE 6 3 — `'�� � — �'/ �� � FAX
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WiNDOWS
❑ BASEMENT FINiSH �OOF ❑ DRAIN TILE
� DECK ❑ SIDtNG ❑ OTHER
❑ SW[MMING POOL
❑ NEW HOME CONSTRUCTlON D ADDITION
❑ MAMTENANCE/REPAIR ❑ REMODELING
ROOFING �
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
❑ Otha
Q HOUSE ONLY
�1-IOUSE & GARAGE
�❑ ATTACHED GARAGE
❑ DETACHED GARAGE
FT
BASEMENT REMODELlNG SUBMIT:
i . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTfON INCLUDiNG DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim I. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of consWction 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:
(LT5ING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chaxge
Due
$ �-1'� , Z5
$
$
$ '
$ �i
$
$
$
$
$ �_ —
$ —� i) l � L.�
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the totai joh 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 pavable to: Citv of Fridlev
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 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 all work which req approval of plan /�/
SIGNATURE OF APPLICANT PRINT NAME �� v�' A(�/�n 2_ DATE %�%`� "' ��
APPROVAL INSPECTOR SI