P - 35714Building
Inspections
763-572-3604
763-502-4977 FAX
DAT '� � r- �- d l �
SITE ADDRESS � �Z
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT►VE f-I-2011
YOUR E-MAIL ADDEtESS
� .,4.-� � I� ��
THIS APPLICANT IS: ❑ OWNER =�ONTRACTOR
PROPERTY OWNER/ NqME: G f{
TENANT .______ ._. � _ �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRiBE WORK BETNG
SIZE OF [MPROVEMENT_
PHONE:
NAME: Cti 1> L, CL %�j�L l��-,
STATE LICENSE #__� O � ��� S` �
ADDRESS •
PHONE f�J �'Z ' 3� -' �I �
�INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDiTION ❑ GARAGE/SHED
CITY
Permit No.: � � �
Received By:
�. :�,:� �, _ � a ,
�
ATE��ZIP��2,.,
� Sy'�-4 C��'e�n �..GG
CERT NLJMBER_� -� � Z O"� �P —I I- O d Z�%/
CITY��/€�C�STATF�ZIP �fTT r
_ FAX
SIZE
STORIES
❑ BA$EMENT FINISH �'ROOF ❑ DRAIN TILE
❑ DECK •�',IDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION O ADDITION
�AINTENANCE/REPAIR ❑ REMODELING
E:L� ��v l� o� T�, l.s�� �n �E �TOF.�T' �%,.� c.5
ROOFING � �� �
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
-�'.HOUSE ONLY
� HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
C Oh lr°k � t
SQ FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
SIDING FOR NEW CONSTRUCTION MCLUDING DECKS,
❑ Vinyl � O O ❑Soffit ADDITIONS. & PORCHES SUBMIT:
�luminum � ❑ Trim 1. Sife Plan/Survey showing the existing structures
��eC � Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE 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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ ��-i '� �• 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
� �� •G� 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 pavable to: Citv of Fridlev Attach
lations
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 a permit and work ' not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of I ' r ir view and approval ofP� s. ' r � ��� l
SIGNATURE OF APPLiCANT PRINT NAMET_�� (�/�-T,� LL.1��j3 DATE � ��
APPROVAL INSPECTOR SIGNATURE