P - 46502Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
Permit No.:
Received By: ► � 1'11"'
��"�e����' � 9 201�
DATE I I/ f D� f I YOUR E-MAIL ADDRESS
SITE ADDRESS 2 SCJ �( S� are �t/�' -��. J cj j<y ��K c-scf32
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OW1vER/ NAME: A-YGJY ��/ �'LC (5 a ��
TENANT pDDRESS: aSd G( S�QV� lVa�' CITY �! ��/ STATE
�l .rt �r z►a ssy3 z
PHONE: S �y / -��- B'�S
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME: �tecuil � �i✓`ST� Cc�vt�6�r'�c�Ic�
STATE LICENSE # I5� L�o .� Sf .3 � 6 LEAD CERT NUMBER
ADDRESS: .Sr�/2 � �2 O�%� �K - CITY h/�oai !K 7 STATEy17 ZIPSS Z
PHONE �5 /-5�6 2- 3 z� 7 FAX N%u-
�-SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ,'t�ROOF ❑ DRAIN TILE
� DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �REMODELING
DESCRIBE WORK BEING DONE: D�e �� �
SIZE OF
O 7� S b
, ROOFING
', NUMBER OF SQUARES i � ' '
, GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SiZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED _
' C� WIDTH � �
�1-10USE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
FT %2aa
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of struc!ural members to be used
FOR NEW CONSTRUCTION RJCLUDING DECKS,
ADDITIONS. & PORCHES 3UBMTT:
l. 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
$ (9 �, � ��
$
$ ,
$
$ `il
$
$
$
$
$
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 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 work 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 in accordance with the
approved plan in the case of all w4r�k which requires review and approval of plans.
SIGNATURE OF APPLICANT > PRINT NAME -� �`� F"- ti �� �->--- DATE 6� % ib I N
APPROVAL INSPECTOR SIGNAT