P - 45216Building
Inspections
763-572-3604
763-502-4977 FAX
DATE / - 1l -
SITE ADDRESS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR nE-MAIL ADDF2ESS
'Tf i � �C' �1
TH[S APPLICANT IS: ❑ OWNER �'�ONTRACTOR
PROPERTY OWNER/ ( NAME: �
TENANT I ,e,DDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
st CiTY �-� � � r�
PHONE:�0.� J� j S ��v �I �
NAME: �u.��G-C C��1�j�'��c "'7 �J`� '�' K2_� �Cc�I0�5
STATE LICENSE #� C� („ a$3 ('s; LEAD CERT NUMBER
ADDRESS:
PHONE ,k�,�- - / b � ` <C� -
�INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
❑ ROOF
❑ SIDING
❑ SWIMMING POOL
FAX
o ;
STORIES -
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TY.PE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: 'i Y., 1`a'c9"�
SIZE OF
ROOFING �
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTfiIG OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENiNG CHANGES &
TYPE OF WINDOW TO BE INSTALLED
�IOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
HEIGHT
Permit No.: �
Received By:
Date Rec'd: � , �
A
STATE ZIP
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FORNEW CONSTRUCTION (NCLUDTNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing sVuctures
and proposed project.
2. Two seu of construction pians
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
- - - - - -- — - _ — - -- - —
ALL FEES ARE BASED ON VALUATION, TNCLUDING THE COST OF LABOR AND MATERTALS:
(USING�� 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ �� `o'Z % v 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
$
$ �-
$ 1
$ � � c�C�
$
$
$
$
$
$ �
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
Ab eement necessary () Non Necessary (
Make checks pavable to: Citv of Fridlev
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D 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 an c es of th City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a pe 't an 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 1 wor which e ires review and approval of plans. -7 g
SIGNATURE OF APPLICANT PRINT NAME �,n �O IJbS DATE ['" 0'� II