P - 45747Building BUILDING Permit No.: ������ � C� �����
Inspections RESIDENTIAL APPLICATION Received By: N �
763-572-3604 CITY OF FRIDLEY Dat���d`� `� �
763-502-4977 FAX EFFECTIVE I-1-2011
DATE ly 4�3 (% " J� YOUR E-MAIL ADDRESS
SITE ADDRESS 5��� s� � � ,
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
❑ OWNER
NAME: .I ��'1 �'1
ADDRESS: � ��� CITY,
PHONE:
STATE ZiP
tVtUV1G. �• vv 1 ivY�c+� Lvr� 1 l�/w�1.7Yti ti-�� V 1�Z�
STATE LICENSE # Z tl�.3 % S I� LEAD CEI2T NLIMBER
ADDRESS: jY3—tI� /J/'�^•� �^� CTTY��/w Lc(u STATE/'^�LIP S'j��/ /
PHONE 7� 3� �I`l.3- %%`��% FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �,OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADD[TION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOIJSE ONLY
❑ HOUSE & GARAGE
� ATTACHED GARAGE
❑ DETACHED GARAGE
OSoffit
❑ Trim
❑ Fascia
LOCATION OF W[NDOWS
NUMBER OF WINDOWS
HEIGHT
FT
BASBMENT REMODELING SUBMIT:
]. Existing Floor Plan
2. Proposed floor plan
3. List of strucmral members to be used
FOR NEW CONSTRUCTION INCLUDTNG DECKS,
ADDITIONS. & PORCHES SUBMIT`
l. Site Pian/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE ST[CKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
$ I LS� �L�
$
$
$ D
$
$
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 ( )
$ �, � j(� Make checks payable to: City of Fridlev Attach
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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
confornnance 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 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 rk ic quires review and approvat of plans �� ��-�'F`."( � /
SIGNATURE OF APPLiCANT PRINT NAME DATE P�O�- /
APPROVAL INSPECTOR SIG TURE