P - 48392Building BUILDING
Inspe�tions RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE I-1-2011
DATE �E% " I�- �" � � YOUR G-MAIL ADDRESS
siTE fwDxess �5 3"7 5� �' �u� �:�E �����.�1 , ►''l►�� 5�5�3 "Z.
THIS APPLICANT [S: ❑ OWNER
PROPERTY OWNER/ N�g: � �� � �;��,��
TENANT pDDRESS: S� � � S(� Y}i�z �� CITY
PHONE: (.�I Z ` �L.� ~ G%I (a> �jJ
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT_
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ V inyl
❑ Aluminum
❑ Other
Permit No.:
Received By:
Date Rec' d:
ATE 1'�J/i,�ZIP .5��[3 Z-
NAME: � L-�ian? 4�4� �.£'S� �I �UJ�,�'�
�
STATE L[CENSE # G� �r�� `G � LEAD CERT NUMBER
.a��RESS: i`Z� �� <����-ti s'Y' N"� ciTV���7;�1�t� sTaTFI�'t�zipS��S�
PHONE IIL. �i _ L .. .31 � FAX 1G+" -° �•� _�,�lLs
SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS /
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE � �����' `�L;`` ( �� ��� r
❑ DECK ❑ SIDING ❑ OTHER P�
❑ SWfMMING POOL 1�ls7vt, tj�Cj t-� Dj�yy�f{�: "
❑ NEW HOME CONSTRUCTION ❑ ADDITION '�
❑ MAINTENANCE/REPAIR '�Q REMODELING � wa�}`i41� Dc.,wv4yc%
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENiNG CHANGES &
TYPE OF WINDOW TO BE INSTALLED
- � it�� � ���k.- ?.�s�,�l,�� °� Tr,»1� �T =i�i-w� �. - ca��� ;�ti� �,P�;ti i - C�.�T�, ,2p�
LENGTH WIDTH HEIGHT SO FT
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WiNDOWS
NUMBER OF WIN
BASEMENT REMODELING SUBMIT:
I. 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 struc[ures
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 $ ���;�Cr'��� I..�,�",yL��` G�L��Ii 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
$
$
$
$
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.00I 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 payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowie,ylge that the information above is complete and accurate; that the wark will be in
conformance with the ardinances and codes ��e Cytj%of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and ��v�'r�C is not to start without a pennit on site; that the work will be in accordance with the
approved plan in the case of il work w ich equir s review and approval of plans.
SIGNATURE OF APPLICANT % � PRINT NAME ,a�� jj��.. /'�O�,d�.;,''� DATE �Cr `I �'� Z-�^ ��___
APPROVAL INSPECTOR SIGNATURE ,�; � , 1 ��-r7
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