P - 35118Building
Inspections
763-572-3604
763-502-4977 F
DATE j%�� � �� �
SITE ADDRESS S9 �
TH[S APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSUR.ANCE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-i-2011
YOUR E-MAIL ADDRESS
❑ OWNER .�60NTRACTOR
.. � F�..� r--r�R�
ADDRESS: �' Ci R' cJ
PHONE: �(p3�•S'� j _Seig 7
CITY
NAME: �'IC-C'. Q-FEFs ( ON �XT E6�i JQ.s � C�-
STATE LICENSE #� 0� G773 O LEAD CERT NL1ME
ADDRESS: SS/ ! /�'` �v� �� CITY
PHONE G�I� -^��i � ^:0 �f �c`� FAX / _rJ —
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DITION
O BASEMENT FINISH
❑ DECK
TY.PE OF WORK:
DESCRIBE WORK BEtNG
❑ GARAGE/SHED �,W[NDOWS
�OOF ❑ DRAIN TILE
❑ SIDING � OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR _ �EMODELING
ROOFING
NUMBER OF SQUARES �a `
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
� Other
❑ HOUSE ONLY
�OUSE & GARAGE
❑ ATTACHED GARAGE
O DETACHED GARAGE
�So�t
❑ Trim
� Fascia
WINDOWS
IN EXISTING OPENINGS'�es ❑No LOCA'
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENMG CHANGES & 1,� S,QL
TYPE OF WINDOW TO BE INSTALLED e'���
��-�� v e Nyvw
OF WINDOWS j�i�C�
J i � ►�-rc 1�17�:+Z`��
NUMBER OF WINDOWS � �
Permit No.: �/ � ��'i � ;� ''�"�
Received By: -
� `'��' �
A
�
STA'
FT
BASEMENT REMODELING SUBMIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of strucwral members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
L Site Plan/Survey showing ffie existing struct�res
and proposed project.
2. Two seu of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE ST[CKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FE CHEDULE)
COTAL JOB VALUATION $ 1$�"'%;�7� — 1'IQO� 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
x ►��'!,S
$
$
$ 1� �
$ $��
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Perrr►it 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 payable to: City of Fridley 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 woric will be in
conformance with the ordinances and codes 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 permit and work is not to start without a permit on site; that the work will be i acc rdance with the
approved plan in the c c 'ch requires review and approval of lan /�c+ c
SIGNATURE dF APPLICA��� PRINT NAME��Yft sL� S�Z'�iCDATE � O II
APPROVAL INSPECTOR SIGNA E .