P - 42136Building BUILDING Pe�it No.: �� � l�' � 7��
Inspections RESIDENTIAL APPLICATION Received By
763-572-3604 CITY OF FRIDLEY Date Rec'd: '
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE l/��� � G/� YOUR E-M�A-IL ADDRESS Cs1., c GY�-L � c. S`f s/!�. 1
SrrE ADDRESS �`Cj Lir.�—� f� �" �v 1`'/�tC/ L-�i.
THIS APPLICANT IS: �WNER ❑CONTRACTOR
PROPERTY OWNER/ Nq�: �-S �% ( „� ��
TENANT AD��ss:��/ �t �— �i� �� /vl� crrx � STATE�ZIP �S`�5�9 ,�
PHONE: /6 � T7 � o� � �j �/ Or- � Io2 o�e 7 S��� �. �i
corrTRacroR N,�: �-_----
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NLTMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PI30NE FAX
PROPERTY TYPE �SINGLE FAMII.,Y/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ��DTTION ❑ GARAGE/SHED � WINDOWS
❑ BASEMENT FIDIISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING �OTHER
❑ SWIIvIlvIING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCElREPAIR � REMODELING
DESCRIBE WORK BEING DONE: G G OI� . .
SIZE OF IMPROVEMENT LENGTH WIDTH �� HEIGFiT S F�?�
� HOUSE ONLY �""""'f�
$ASEMENT REMQI�ELING S_�v�
NRU�MB�ERGOF SQUARES ❑ HOUSE & GARAGE 1. Existing Ftoor Plan
C,�ARAGLS ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACFIED GARAGE 3. List of struchual members to be used
PROPOSED HEIGHT:
SIDING FORNEW CONSTRUCTION INCLUDING DECKS,
� Vinyl ❑Soffit ADDTTIONS_ & PQ�CHES SIIBMIT:
❑ Aiuminum ❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other � Fsscia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EX[STING OPEIVINGS OYes �No LOCATION OF WINDOWS FOR WINDOWS – PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRiBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES 8c
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASF4IZON VALUATION, INCLUDING THE COST OF LABOR AND MATEWALS:
TOTAL JOB VALUA
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
THE 199'7 U.B.0 FEE SCHEDULE)
OCCUP.
$
$
$
$
$
$ .
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 (Plaris to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: Cityo uf Fridle_y Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge that the informarion 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 Constiuction Codes; that I understand this is not a
ptrmit but only an application for a �ermit and work is not to start without a permit on si ; that the work will be in accordance with the
appmved plan in the case o 1 • � lwhich requires review and approval of pl s. ,) � Gr
SIGNATURE OF APPLICANT f PRINT NA GS � DATE'_�,�"_
ADDDAI/Ai iATQDIIl�Tl�D CT!!iJA TDII
SEPARATE PERMITS ARE REQUIItED FOR PLUMBING, ELECTRICAL AND MECHANICAL WOR�
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