P - 45830Building
Inspections
763-572-3604
763-502-4977 FAX
DATE (�j � p�(..� —
STTE ADDRESS �,�
THIS APPLICANT IS:
BUILDING
Permit No.:
RESIDENTIAL APPLICATION Received By: ( ' `
CITY OF FRIDLEY Date �y���
EFFECTIVE 1-1-2011
� �� YOURE-MAILADDRESS (_ 5���(I�,SLO���� Q�,��PS.�_ C.O/i�
❑ OWNER
PROPERTY OWNER/ NAME: �/���{,�_��T�j�
TENANT ADDRESS: .��'%�E c1�
PHONE�[�3 �S/I fO���
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
STATE ZIP
STATE LICENSE # �"j � LEAD CERT NUMBER
ADDRESS:Li/>b l� ACIfAIZ� I,/� �/f> S CITY��PLE �RD� STATE�ZIP `�',S J
PHONE lLr.�-�'/u��-�- N %�`/
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
FAX
sizE
STORIES
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH � ROOF
❑ DECK �SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�vIAINTENANC�/REPAIR � REMODELING
DESCRIBE WORK BEING�ONE:
S1ZE OF IMPROVEMEr. . _ _
0
❑ DRAIN TILE
❑ OTHER
S
HEIGHT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING 5UBMIT:
l. Eacisting Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED S1ZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS & PORCHES SUBMIT:
❑ Aluminum ❑ Trim I. Site Plan/Survey showing the existing structures
and proposed project.
Other«�����,5 S�E'L, '� Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPEI�IINGS-DESCRIBE SIZE OF MANUFACTLJRE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
n (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION S 7._ ���% �`� OCCUPANCY TYPE
Permit Fee
Plan Rsview
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
����
�.
� ..�
rl�
$
$
$
$
$ �r'Y') �?
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 navable to: City of Frid}ev 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 a#►' d c3ti s of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a per ' nd rk is �to s rt without a permit on site; that the work will be in accordance with the
approved plan in the case of k ir s re ' re�a�of pl���/�����,r •/ ��O -��—
SIGNATURE OF APPLICANT RINT NAME aGV// DATE �'-
APPROVAL INSPECTOR SIGN
PLEASE NOTE: SEPARA.TE PE RE UIRED FOR PLUMBING, ELECTRICAL AND MEGHANICAL WORK