P - 46254Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No. �
Received By:
DatR� d�
DATE � � .Z ,Z. � /I YOUR E-MAIL ADDRE5S (/yt�i �Q ��'�'�''' � ^�-��'
SITE ADDRESS / b0 / � �0 7 � ✓� /1�� _ � �/,J�f' � I�i� sr�32
THIS APPLICAI3T IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NA�vt�: �.c�e,�, lYloor,G
TENANT �DRESS: � DO/ �(e 7� i�J/t NE CITY /�sYi�.1�1 STATE��f�'ZIP J�Y �•;�
PHONE: (�/ Z-? 39 - o S$ S
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
c
STATE LICENSE # a Gb 30� S Y LEAD CERT Ni3MBER iv.�t= 6 y,z-89 ^�
ADDRESS: �O(� �j'Q 1�i���M6 ,$/y1 i✓� CITY uQnv�ea STATEN�[ZIP �'se g2
{il' SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ �nlTiarr tJ GARAG
❑ BASEMENT FINISH $(ROOF
❑ DECK O SIDING
TYPE OF WORK: �❑ NEW HOME CONSTRUCTION
�( MAINTENANGE/REPAIR
DESCRIBE WORK BEII3G DONE:
ROOFING
NUMBER OF SQUARES � �e
C���1GES
PROPOSED SIZE:
PROPOSED HEIGHT:
FAx 76_�— !r3 y-
SIZE
STORIES
i1SHED ❑ WiNDOWS
0 DRAIN TILE
❑ OTHER
NG POOL
❑ ADDITION
❑ REMODELING
�-c� 9�C/y.�
--�—T
_ _ _ WIDTH__ _ HEIGHT
❑ HOUSE ONLY
�HOUSE & GARAGE
�(ATTACHED GARAGE
O DETACHED GARAGE
FT
BASEMENT REMODEL�IVG SUBA�IT:
1. Existing Floor Plan
2. Proposed floor plan
3. L ist of structurai members to be used
SIDING FOR NEW COI35TRt3CTION INCLUDING DECKS,
❑ Vinyl ❑Soffit AD�ITT�INS. & PORrIiES SUSMI�'•
❑ Aluminum C] Trirn i. Site P1an/Survey slsowing tfie existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calcularions
IN BXTSTING OPENII�IGS OYes ONo LOCATION OF WINDOWS FOR WINDOWS -- PROVIDE U-VALLTE AND
OR FOR I�iEW OPEIVINGS-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)
'OTAL JOB VALUATION $ �/ D. 0 06 " OCCUPANCY TYPE
Permit Fee
Pian Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ J
$
$ 5
$
$
$
$
$
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 payable to: City of Fridley Athac
THIS TS AN APPLICATION FOR A PERMIT-NOT VAL1D iTNTIL 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 for a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved p]an in the case ,a�ll w�� h re es �ew and approval of plans. /�,�
SIGNATURE OF APPLICANTd� �/ ���j�PRINT NAME T��/if�(f(%�"/f DATE 6 isZpZ �'��
APPROVAL INSPECTOR SIGNA�—