P - 39649Building
Inspections
763-572-3604
763-502-4977 AX
DATE � � �
SITE ADDRESS � / ,
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No� � � �
Received By����
Date Rec'd: �' �(
YOUR E-MA1L ADDRESS ,/�� r! �C'1 �} u%t?,�7f'„r' !/!G � CO/yj
THIS APPLICANT IS: ❑ OWNER C}�CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIfiICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME:__ �cr�r'.`Crti J`�!'��n�tE't
ADDRESS: �`' � �v � � LrlM� � � CiTY
PHONE: '7f `? -- S„7/— `� /.� c'S
NAME:�p 2�3t � �C �et_ :
STATE LICENSE # �O(� ,}� ��a ]% LEAD CERT NUMBER
PHONE (v / � ' /'( }j ` � / d"C,
fai'SINGLE FAMILY/NEW COt�1STRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
SIZE OE IMPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
� Vinyl
❑ Aluminum
❑ Other
r�
CITY
FAX �7'"%
SiZE �Ga"
STORIES
�ROOF ❑ DRA]N TILE
❑ SIDING ❑ OTHER
❑ SWIMM(NG POOL
O ADDITION
� REMODELING
❑ HOUSE ONLY
I$ HOUSE & GARAGE
1JATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
ATE�ZIP S .S~L/3 ..Z
ATE%�/vZIP �s�3 �..z
FT
BASEMENT REMObEL1NG SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of constniction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANLTFACTURE 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 T 1997 U.� FEE SCHEDULE)
COTAL 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
$ �i1 . ��
$
$ .
$ .
$ �-c`iJ
$
$
$
$
$
$ %�
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 (P(ans 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
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROC�SSED
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 tt�e 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 f a rmit a or is not to start without a permit on site; that the work will be in a cordance with the
approved plan in the case of all or which y�view and approval of pla�S / ��
S(GNATURE OF A.PPLICANT 'y PRINT NAME JO /2 �i - 4JL� ��°/ DATE � 3 I l%