P - 47399Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.�i�� � � � �j
Received By:
Da�[���alUN 14 2011
DATE_ �V r`��' �� �o �/ YOUR E-MA[L ADDRESS % S(c�Y�s2 S KV l�1 �rr°1���(�e�/��L �'Q �
sITE,a�DRESS �Q! !� / Sr A-V �'�1�. r,i2.[A�ty /'7n! 5S�f3 Z—
THIS APPLiCANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMRNT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑CONTRACTOR
ADDRESS: f-t-91 / s—r 1"�()� �'1/C CITY 1�2/D L��� STATE�%LZ[P 5 5 7—.3 Z
PHON�7�3� � 7/ -3�7 f� ��� ) SC�g _� 3 3�'
NAME: s �=' L i
STATE LICENSE #
ADDRESS:
SINGLE FAMILY/NEW CONSTRUCTION
❑ WO FAMILY/NEW CONSTRUCTION
D CERT NUMBER
FAX
SIZE
STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINiSH ❑ ROOF ❑ DRAM TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
CITY
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
�j-IOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
� Fascia
LOCATION OF WINDOWS
NUMBER OF wTNn�ws
STATE ZIP.
FT
BASEMENT REMODELING SUBMIT
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION RJCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT•
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
Permrt Fee " — - -
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$ � 3�i
$ ..
$
$
$
$
$
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 Fridlev
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 Fr' ley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a per it d rk is n to start without a permit on site; that the work will be in accordance with the
approved plan in the case of �' ork w q e � an approvai of pl,� s. n / )< --
SIGNATURE OF APPLICANT ' � PRINT NAME_L �i1Q�/�j J`�. �,SLLd �,�"��ATE (p '� /✓ �����
APPROVAL INSPECTOR SI T ATIIRF