P - 40826Building
Inspections
763-572-3604
763-502-4977 FAX
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SITE
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BUILDING
RESIDENTIAL APPLICATION
THIS APPLICANT IS: ❑ OWNER
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
Permit No.:
Received By: ,f v �P�7�
�
Date ��� _
YOURE-MAILADDRESS {��"llienvint�%�i' I�J �u./��'•L��T.� l�iw� � C�:n.�
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PROPERTY OWNER/ I NA1v1E:��n � � i L� C � ti C. �
TENANT ,q�DRES3: �IC� f,a��'� �/�'ti- v C[TY
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
STATE����IP.
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: �� ��--- V,n, i U-eJ� S�� �J-'L_. CTTY��� STAT��ZIP
PHONE __ �S 7 ( �l� ,7j �j FAX �
� SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �f ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�d MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: CG Cf � G�
SIZE OF IMPROVEMENT.
ROOFING
NUMBER OF SQUARES _�� �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYAE OF W[NDOW TO BE INSTALLED
�7 HOUSE ONLY
� ❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
WIDTH _ HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members ro be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCNES 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 $ �(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
$ � � LS
$
$ ��
$
$ �
$
$
$
$
$
$ .Ua
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 Stiqulations
THIS IS AN APPLlCATION 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 applic tion fo a permit and work is not to start without a permit on site; that the work wiil be in accordance with the
approved plan in the case o al rk which requires review and approval of pl s. / 1
SIGNATURE OF APPLICANT PRINT NAME �� in C��[ Ov� , DATE �O'��/lI
APPROVAL INSPECTOR SIGNATU