P - 42835Building �
Inspections
763-572-3604
763-502-4977 FAX
DATE r'' 1 1� ►
SITE ADDRESS �
THIS`t1PPL[CANT IS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201 l
_ C� � -�'�-� 1
�OWNER
PROPERTY OWNER/ I,NAME:
TENANT , j QnnRF
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
YOUR E-MAIL ADDRESS
❑CONTRACTOR
..- �--� �7 -4' VL
PHONE: i � � � �� � 7 - �" D {l'� i 1
NAME:
STATE LICENSE #
ADDRESS�
PHONE
SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCT[ON
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINiSH f�..ROOF
❑ DECK O SIDING
❑ SWIMMING POOL
_ �
CITY �V�c
LEAD CERT NUMBER
Permit No.: �U� ! Uox lv�J
Received By:
Dat��a�C;`� 1 � �6��
� �t� � 1� U � P I.�7 o Vc
STATN! "11L1 Z[P f�"s�--i�-{ _��
CITY STATE
FAX
SiZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
I� MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: ��' ' �.
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUM$ER OF SQUARES � ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ A(uminum
❑ Other
I WINDOWS
�i iN BXI5TING OPENINGS ❑Yes ONo
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
�' TYPE OF WINDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
HEIGHT
FT
r.�i�
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION �NCLUDING 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 $ __ _ 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
$
$ ��
$ ��
$
$
$
$
$
$ J.5
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 ( )
Make checks oavable to: Citv of Fridtev 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 1 understand this is not a
permit but only an application ar a perm' 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 al k w�c r q'res re�ie and approval of p a .
SIGNATURE OF APPLIC .� � -` � I/ PRINT NAME �C' � Gc DATE C� L l
APPROVAL [NSPECTOR SIGNAT E