P - 45291Building
Inspections
763-572-3604
763-502-4977 FAX
DATE I `I � �` � r
S[TE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR MAIL ADDF2ESS SGjt��M'1 E�.r7y_,
��C��'��f� .��1 ss ���...
❑ OWNER $�CONTF
NAME: ���CL'�i�! Li4��s
ADDRESS: �EJ �(� !: +
PHONE: ! �.j �J� C� �. '�
�.vi� i ic�►t, i v►c NAME: ����1 ����r'sY�'l"�� G�i1 l.r'� ��.
SUBMIT A COPY OF �"�
YOUR STATE LICENSE STATE LICENSE # (jl,t:t.i"t� � LEAD CERT NUM
AND CERTIFICATE OF ADDRESS: Z � Ga� idL� �' CITY
INSURANCE PHONE • ,� "` •. , �C.��3 �- FAX �i'�
PROPERTY TYPE �; SINGLE FAMILY/NEW CONSTRUCTION SIZE�,�
� TWO FAMILYMEW CONSTRUCTION STORIES /
PERMIT TYPE � �DITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK �SIDING
❑ SWIMMING POOL
TY.PE OF WORK: ❑ EW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELTNG
DESCRIBE WORK BETNG DONE: C� ''' � L'�( � S' �sh �✓1 � cf1 � tf.
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOF7NG ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGES �ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
S�Vinyl � o�t
❑ Aluminum ❑ Trim
❑ Other �Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF W[NDOW TO BE INSTALLED NUMBER OF WINDOWS
u wiNVUw� �
❑ DRAIN TILE
❑ OTHER
Permit No.• ,�71( -UI
Received By:
Date Rec'd: % �' j I�
�S'�G r�tX�/ C) rt11 �vi � , C�C�
ATE,i�ZIP,��y3 �-
' /Y 1 "G .a� '/ f� "/
l++�.�! S. STATEJ�ZIP�7��Z/
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HEIGHT SQ FT
BASEMENT RE�fODELItJG SUBMtT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDINC DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu 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)
fOTAL JOB VALUATION $ D Q = OCCUPANCY TYPE
Permit Fee $ 'S , p?�j See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ , .001 times the total job valuation
Surcharge $ `, .0005 x Permit Valuation Minimum $5.00
License Surcharge $ � j, $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due o �,. �; Make checks payable to: City of Fridiey Attach Stipulations
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 compfete 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 �o,�•k w' requires review and approval of plans1 i % ^� �
SIGNATURE OF APPLICANT ,���wr;��� PRINT NAME �7���Yj�1 �!.?/�pir� DATE /''% 2=� ,�
APPROVAL INSPECTOR SIGNA� UR