P - 39980Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
j DATE ��' � Cj� "�� YOUR E-MAIL ADDRESS
SITE ADDRESS ��J�% �) ��� �� L-v'"i G1 ��' i-/ f'7/%�1
THIS APPLICANT IS: ❑ OWNER ONTR
PROPERTY OWNER/ NAtv1E: lt'S �, ;�� "
TENANT . ��.,.,,,,, ��; F� ��,
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICBNSE
AND CERTIFICATE OF
INSLTRANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
PHONE: �%�Z —
CITY
Permit No.:
�
Received By:�� � "'��� �
��'1�e�'�:P � �_ 2 � 1 �'—__
STATE }�/�D�I ZIP�
NAME: L~�.'��' <f- C�I�tC.f2G f L_ f:' 'r2-7`�'e� G.-"�'�Y`
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: L' f� � �' c,C CITY /j l't f C,lt(,.'( /r� STATE �'/ ZIP �-GC� �
PHONE `� -- � _ Gr ._ �� t� FAX
� SINGLE FAMILY/NEW CONSTRUCTION SIZE
� TWO FAMILY/NEW CONSTRUCTION STORIES_�
O ADDITION ❑ GARAGE/SHED CI WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
O DECK ❑ SIDING ❑ OTFiER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTiON ❑ ADDITION
❑ MAINTENANCE/REPAIR _. ❑ REMODELING
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIAING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes C]No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
LENGTH W1DTH HEIGHT
❑ HOUSE ONLY
�OUSE & GARAGE
❑ AT7'ACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
FT
BASEMENT REMODELING SUBMIT:
I . 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 $ OCCUPANCY TYPE
Pertnit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� L+�7 L `�
$
$ ; , (,i?'
� 4^,
$
$
$
$
$
$
$ ^l:�''��,'�
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 . Attach
THIS IS AN APPL[CATION FOR A PERMIT-NOT VALID 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 of a_ll,,.-�w� requires rev� nd approval of plans. /
SIGNATURE OF APPLICANT �` ��lSl-.�-e.� PRINT NAME �� /?Z L�' � DATE ��5 � I i
AnDDII\)A� TT.LC�nT.l�Tlln (�Tl�I.tATTinI^. /��-°�