P - 44114Building BUILDING Permit No.: �} � {�7�
Ins ections `
p RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY ��'[�d��:� 1�` ��
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE i p� f7~ /� YOUR E-MAIL ADDRESS
SITE ADDRESS �/� � �r � �"'� L�-
THIS APPLICANT [S: ❑ OWNER CONTRACTOR
PROPERTY OWNER/ NqME --
TENANT ,qDDRESS:
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
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NAME: ��/7�'�,/✓�- E,:/�f �Cil�O/,�S' ��1/L
STATE LICENSE #�rZ� v��ei, 7 LEAD CERT NUMBEF
ADDRESS: �j�/j� /�,�� G�� N� CITY�
PHONE �7da��� %/0'"� -- � (7 �U FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/hlEW CONSTRUCTION STORIES
❑ ADDITION ❑_� AGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH LYROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER �
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: !z d —�
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING ❑� USE ONLY
NUMBER OF SQUARES � �HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
S[DING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCAT[ON OF WINDOWS
OF WINDOWS
HEIGHT
ATE%�i Z[P
ATE/�IP.
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCT[ON MCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. 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 $ S?' S C� �. D�li 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
$ �I 'I- �S
$
$
$ �
$ fi�
$
$
$
$
$
$ �'� l0 ��
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 [S AN APPL[CATION FOR A PERMIT-NOT VAL1D 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}�' k w ��requires review and approval of plan �. / / /
SIGNATURE OF APPLICANT Gy��'�,�- PRINT NAME �CT{�CI�t/�s✓ DATE �� ��'=� Dl �
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