P - 40844Building
Inspections
763-572-3604
763-502-4977 FAX
DATE , % S I
SITE ADDRESS S, l
BUILDING � - ''`�'
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
THIS APPLICANT IS: ❑ OWNER
�
YOUR
� �/�i'�—.
Permit No.: � �����
Received By:
Date Rec'd: % /,Z��/!,
PROPERTY OWNER/ NAME: � .� �.;�, LL1 �
TENANT pDDRESS: �,� �" �C '� T F� CITY � STATE i ZIP j S��i Z
�
PHONE.: ` (p � 'S%% 'D���G/2. °O�PG�'3"l;s�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
STATE LICENSE #
ADDRESS:
,D CERT NUMBER
CiTY �%��?L-Q, � N�.. STAT � ZIP_��
FAX �� Y 1' :� F( f ��f1 � P��t ,` 1 l( L'l, Yi:Z �.`(��tY1 .
PROPERTY TYPE /NEW CONSTRUCTION sizE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK O_SIDING ❑ OTHER
�SWIMMING POOL
TYPE OF WORK:
DESCRIBE WORK BEING DONE
SIZE OF IMPROVEMENT ,
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ NEW HOME CONSTRUC'
❑ MAINTENANCE/REPAIR
�%',li! l7 .yi/'/ L-f", �
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
I11�1�[t)�.I
❑ ADDITION
❑ REMODELING
f�� i }'��Y�Z_ L�dC,
� ' � WIDTH �'" �
C] HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
��, ry�`/ z;� J �4-c� ��! r7J NaS /� p�{I!° .
J �
HEIGHT SQ FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members [o be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMTT:
I. 5ite 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 $ �0�3L, /°iT°LG+�� u-f 0%r�"l�oJ2/��'��3�/�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
$ '
$ ��
$ `5
$
$
$
$
$
$
$ �ln �'1
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
lations
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D UNTIL PROCESSED
I hereby apply for a building permit d I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances an ode f the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for erm' and work is not o start ithout a permit on site; that the work will be in accordance with the
approved plan in the case wo i re ' s revi nd ap oval o� pians. l
SIGNATURE OF APPLICANT T NAME N/C�OLAS OLS�'N DATE � 5 I
APPROVAL INSPECTOR SI A // / rr .� ..
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