P - 48337Building
Inspections
763-572-3604
7 6 3- 5 0 2. -4.� 7.7_ _E�X
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.: i�� �� '
Received By:
Date Rec'd:
DATE�%/ ( � YOUR E-MAIL ADDRESS �AT � ���'.�CU:�I,�j'�y (j•ii j Di''�s� . �v':.�
SITE ADDRESS ytt^� NF S 7 rt�'� Pf ��c �'-a2zi)�= v%
THIS APPLICANT [S:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSUR.ANCE
❑ OWNER �CONTRACTOR
.. 2r�rr's�z s3.�w k.
ADDRESS: cn�: ti il �Y�! C1TY
PHONE:
NAME: �C-A\ �i,7�J L ty (3�1.1��25 ,�!�% �- �
STATE LICENSE # Zl'U�gy 8w � LEAD CERT NLIMBER
ADDRESS: ►S�L$ (t�/�� ��� CITYC-Ik I�7vr:
PHONE �U I 2 `7 ��`L " � � 3 �
PROPERTY TYPE �CSINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ ADDITION
❑ BASEMENT FiNiSH
❑ DECK
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
❑ NEW HOME CONSTRUCTION
MAINTENANCE/REPAIR
t 1�G �C� �
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 W[NDOW TO BE INSTALLED
❑ GARAGE/SHED
,`�.$OOF
❑ SIDiNG
❑ SWIMMING POOL
O ADDITION
�CJ REMODEL
FAX
SIZE
STORIES
LENGTH W IDTH
❑ HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCAT]ON OF WINDOWS
NUMBER OF WINDOWS
❑ DRAIN TILE
❑ OTHER
HEIGHT
STATE ZIP
ATE'U'� ZIP Ss�j3 v
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDiNG 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)
COTAL JOB VALUATION ��U�'�� 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
$ l� %, �-�
$
$
$ ,
$ �, r --'
$
$
$
$
—$� . ...
� l � i, �.1/�,
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 pavable to: City of Fridley Attach
tions
THIS IS AN APPLICATION FOR A PERM]T-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 f the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for per it a d 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 k w ch re u' review and approval of plan�.J ,.� /�
SIGNATURE OF APPLICANT �� PRINT NAME / A'+� ��`J � S DATE ��l �
APPROVAL 1NSPECTOR SIGNATURE
S-��i