P - 46255Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATIUN
CITY OF FRIDLE�
EFFECTNE 1-1-2�11
Permit No.: �� ��� � ���
Received By:
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DATE �' o� 07•" I� YOUR E-MAIL ADDRESS l�n��, •, its�� ___ _
SITE ADDRESS � O// ��7 � i�G N E i �Y�d l�'''1 � MNi SS y32
THIS APPLICANT IS: ❑ OWNER �P[CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BE1NG
SIZE OF IMPROVEMENT
aDD�ss: io/I -�7 �'.�+k /�� ciTY��;�/� sTa��ztr SS�f3z
PHONE: %63" �%/-' %D33
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STATE LICENSE # qiD6 3053 y LEAD CERT NUMBER ��?- 6 s�a 8 9"�
ADDRESS: .7U69D Vi Kr►�y �✓d /�E' CITY �✓ O i STATEt'%NZIP SSd `I�
PHONE 763- y9y �6 �� Fax 7b 3- S� Y- Yy7
�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
� BASEMENT FINISH �ROOF
O DECK ❑ SIDING
❑ NEW HOME CONSTRUCTION
�d MAINTENANCE/REPAIR
❑ ADDITION
❑ REMODELING
❑ DRAIN TILE
❑ OTHER
FT
RQUFIN� qa ❑ HOUSE ONLY BASE REMODELING SUBMIT:
NLJMBER OF SQUARES a� a �f HOUSE & GARAGE 1. Existing Ftoor Plan
G R�GES„ � ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of strvcturai members to be used
PROPOSED HEIGHT: �
SIDING �� FORNEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl []Soffit j� ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim � 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
W WS 3. �nergy Calculations
IN EXISTING OPEIVINGS OYes DNo LOCATION OF WINDOWS �OR WINDOWS - PROVIDE U-VALLJE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OP 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 $ $, pA D OCCUPANCY TYPE.
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota! Due
u,���.
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 navable to: Citv of Fridlev Attac
THIS IS AN APPLTCATION FOR A PERMIT-NOT VAI,ID 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 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 d��l� eq ' s r and approval of pl�
SIGNATURE OF APl'LICANT /� PRINT NAME <o a✓4� �I�[ U'�i�� DATE G" e�Z,Z. ",l�