P - 35591Building BUILDING
Inspections RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE I-1-2011
DATE 4% -�' `-�' YOUR E-MAIL ADDRESS
SITE ADDRESS __ 3� I �P� IA V� �� i
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
— <� % 4
Permit No.:
Received By:
Date Rec'd: � � t
PROPERTY OWNER/ NAME:_ S Y� � h i'v1 IZo 2 LA
TENANT pDDRESS: ,� 5� t! 1��' A li� N�- CITY � V`� d�-e �_STATE ZIP
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
�c�ZIC�IN �ot> -�= t v�, lT �<.�2w�,oc��� i►�.
STATE LICENSE #
ADDRESS: P��'
°Z � 3 -- "7 8'C. °
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE
TYPE OF WORK:
❑ BASEMENT FINiSH ROOF
❑ DECK �iDING
/ O SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �EMC�DEL
_— --
DESCRIBE WORK BEING DONE: ����►�4 �J US � t. Eoccrc���
ROOFING
NUMBER OF SQUAR6S
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
�myl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS/�es �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
L CATION OF WINDOWS
�trov�-} �v1 ri�oW �
NUMBER OF
�D CERT NUMBER
CiTY �� 01'l. L� IC�f STATE� ZIP S S 3 d�
F,e,�t S �t � �
SIZE
STORIES
❑ DRAIN TILE
❑ OTHER
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDiTIONS. & PORCHES SUBMIT:
L 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 $ %S� �� 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
$ � ��2�'
$
$ ��
$ y, f
� �F�
$
��
�:�r�
See Back Page for Fee Schedule
65% of Building Permit Fee
.00I 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 Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 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 perm' rk is not to start ' out a permit on site; that the work will be in accordance with the
approved plan in the case of all work w' h r uires 'e roval of plans. v
SIGNATURE OF APPLICANT RINT NAME �.T�i,WL�P S��'� Y'S tQ(,1- DATE `?'a' �-� �
APPROVAL INSPECTOR SIGNATURE