P - 39388Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � — � �
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
�
❑ OWNER
NAME: � \�C.�A J�
Permit No.:
Received By:
CITY OF FRIDLEY r.���e� ea n�"�n1�
EFFECTIVE 1-1-2011
`�YOUR�E-^M;IL ADDFtESS �Y �°�� ��. °2-jC.�taniYS 4�- l_TIM���• C�"^'�
� 6v
ADDRESS: �� � � b� �U¢— �� CTTY �+! �
PHONE: U3'— ( � �U
CONTRACTOR NAME: tP�W�-�v ,
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE #
AND CERTIFICATE OF ADDRESS:�
INSURANCE pHOAIE (1�I vj^ O
`�.�cv �o�
� S+
PROPERTY TYP��INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION �
PERMIT TYPE
ATE 1 "��� ZtP
CERT NUMBER
CITY ��-� STATEM,VZiP ��
FAX
SIZE
STORIES
❑ BASEMENT FINISH i�"ROOF O DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: I❑ NEW HOME CONSTRUCTiON ❑�f)ITION
❑ MAINTENANCE/REPAIR Ca'(2EMODELING
DESCRIBE WORK BEING DONE:
ROOFING 2�
NUMBER OF SQUARES c�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
C�Ci'� 1/�a'�`+•t G,�
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONS?RUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. 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 MATERI.
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB �ALUATION $% J,, � cd ' OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
$urcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� `�
$
$
$ �
$ �
$
$
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 aavable to: Citv of Fridlev
Attach
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCBSSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work wiil 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 work wh1i�ch ��'res review and approval ofR� ns.
SIGNATURE OF APPLICANT G%%'f """ PRiNT NAME F�iaV'� U�``^S DATE Q��— I�
APPROVAL INSPECTOR SIGN� T—