P - 45685Building
Inspections
763-572-3604
763-502-4977 FAX
SITE ADDRESS _
THIS APPLICANT IS
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
0 OWNER �;9NTRACTOR
PROPERTY OWNER/ I N�:=
TENANT
ADDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERNIIT TYPE
rn�i�c: / lr�J —..=J/�� �'
NfiiVIE' � l.i Lk ���n° L� t�'"
STATE LICENSE # ,�'j C'� Cl O�p G
ADDRESS: _ � ���____��( �% 7 ii
Px9rtE % L�.-3 — `7��—/�7�
SINGLE FAMIT.Y/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITTON ❑ GE/SHED
❑ BASEMENT FT2VISH ROOF
� DECK ❑ SIDING
O SWIMMING POOL
l'D CERT
FAX —
Permit No..na� �l-t1�oZ
Received By: f ' '�
i`r. �. ��' �.�
�
3ER /V /`i-'T' ` v�- / �
�17YinG c�,c.O�STATI
�
SIZE
STORIES
❑ WINDOWS
❑ I?RAIN TILE
❑ OTFiER
_ _ --
TYPE OF WORK: ❑ W HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ��� 6�%�= � ��' -�" CCi C� —
SIZE OF IMPROVEMENT LINGTH WIDTH
ROOFING ❑ HOUSE ONLY
NUMBER OP SQUARES �_ �`HOUSE & GARAGE
GARAGES
PROPOSID SIZE:
PROPOSED HEIGH"I':
SIDIlYG
o V�yl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
� DETACHED GARAGE
l;���e �i�l
FT
BASEMENT REMODELING SUBMIT•
] . Existing Floor Plan
2. � Propos�i floor plan
3. List of slruchual members to be used
FOR NEW CONSTRUCTTON INCLUDING DECKS,
OSoffit �DITIONS & PORCHES SUBMIT�
❑ Trim 1. Site PlanlSurvey showing the existing structures
❑ Fascia and proposed project.
2 Two sets of construction lans
P
WINDOVVS 3. Energy Calculations
IN EXISTING OPEI�IINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALIJE AND
OR FOR NEW OPENRQGS-DESCRIBE SIZE OF MANUFACTIJRE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NtJMBER OF WINL�WS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(ITSING TH� 1997 U.B.0 FEE SCHEDiTLE)
TOTAL JOB VALUATION $'� 39 7. c,�t� nrrrrne�vrv Tvn�
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � 3. L 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 P1an 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 UIVTIL 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 work ' not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all o k whi h req ' es r evy and approval of plans. /�, .
SIGNATURE OF APPLICANT r.. NAME_ _/�l�'�/Ct/ /�d /721.5 DATE_ � O-�—I�
APPROVAL INSPECTOR SIGNATiIRF. _