P - 43794Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I � ~ � �- ' � �
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS �'1� Co I-C l2
Permit No.:��"� � �� 0���'�
Received By: �
Date��: ��� � � ���
SITE ADDRESS
THIS APPLICANT IS: ❑ OWNER � CONTRACTOR
PROPERTY OWNER/ NAME: Q.V1 U S v�n S3n�cv p-r-
TENANT ,e,DDRESS: S%S' -s7 �� %JY'�- Y✓� CITY_ �;2; O%L�'1�1 STATE_�Z[P SS `JJ 2
PHONE: '7 {. 3• rZ � 7� a 99 9
CONTRACTOR NAME: F�1 ��-2 tZ '� Co-Y, s{�,� c. �/ cr► �
SUBMIT A COPY OF STATE LICENSE # g� `�O(o3 1�O Co LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: G p 1 4�y '� ,^,,� ,� �,.� �U CITY���,!_ _., STATE t� ZIP�
INSURANCE PH,QNE ��r 3•- 7'% a. - S,�''a.nl FAX �i,.,, t/.�.��—
PROPERTY TYPE
PERMIT TYPE
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ARAGE/SHED
❑ BASEMENT FINISH OOF
❑ DECK IDING
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE: (O •'l � �
SIZE OF IMPROVEMENT LENGTH t et'
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ��� ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPEIVINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WMDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
SIZE
STORIES
❑ WINDOWS
❑ DRAM TILE
❑ OTHER
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets 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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ ��O� , O n 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
$ raS�as
$
$
$ a
$ �
$
$
$
$
$
$ I , R •q,�
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the tota] 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 payable to: City of Fridle_y Attach
THIS [S 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 wi11 be in
conformance with the ordinances and co s of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicati r a it 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 all o which requires review and approval of plans� �. /r / f ` `� '� ��,� ��
SIGNATURE OF APPLIC �-- PRINT NAME /1--�7� 1i1�`L•� DATE
APPROVAL INSPECTO SIGNA
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