P - 46250Building BUILDING P���c No.:(�� 1zJ + v ��
Inspections RESIDENTIAL APPLICATION Received : ��� ��
763-572 3604 jTY F RIDLEY vate Rec'��
763-502-4977 FAX C 0 F
EFFECTIVE 1-1-2011
DATE � � �Z � — II YOUR E-MAIL ADDRESS /•7� � � �OYY1276t+u17 Y'PS To �--� O11 . ft �. l
siTE ADD�ss s9 a y- 6�it/�� Fr id �e�►T �-t N,, S S�/3Z ,
THIS APPLICANT IS: ❑ OWI�iER �CONTRACTOR
PROPERTY OWNERJ
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEII�iG
T
.a,DD�ss: s9a y-�'F'` S� �E ciTY F��d� sTa��n zir SS'/3 2
PHONE: TG3 — 639" % %OS
f�G���".1�
A/ Z'i
STATE LICENSE #.Z �I 3 bS3 H LEAD CERT
PHONE 7�.5 — �/ yY �
� SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAG
O BASEMENT FINISH ,L�ROOF
❑ DECK ❑ SIDII�iG
O SWIMM
❑ NEW HOME CONSTRUCTION
1� MAINTENANCElREPAIR
NU�MBER OF SQUARES cY.0
GARAGES
PROPC)5ED SI�E:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
V _F CITY�
F� 7�3-y
SIZE
STORIES /
i/SHED ❑ W[NDOWS
❑ DRAIN TILE
❑ OTHER
NG POOL
❑ ADDITION
❑ REMODELII3G
�/a �.e.. _ /oo L < i�arcra
'�CHOUSE ONLY
CJ HOUSE & GARAGE
[7 ATTACHED GARAGE
❑ DETACI-IED GARAGE
ClSoti3t
❑ Trim `
j� Fascia —( Oo � 1�C�0..K
W�iDOWS
IN EXISTING OPENIDIGS C7Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPEI�IINGS-DESCRIBE SIZE OF
OPENING CHANGES &
=�S1289-/
TATE�(�[,ZIP��I�
FT
�1SEMENT REMODELING SUBMIT:
1. Exisdng Floor Plan
2. Proposed floor plan
3. List of shvctural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
DDITIO�IS• & PORCT-IE$ StJBMIT:
1. Site Plan/Survey showing the existing struchues
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:
� (USiN�G THE 1997 U.B.0 FEE SCHEDULE)
JOB VALUATION S OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
5ewer Main Charge
$ �
$
$
$
See Back Page for Fee Schedule
65°/a 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+&ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make c!►ecks payabie to: City of Fridley Attac
THIS IS AN APPLICATIOI3 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 peimit on site; that the work will be in accordance with the
approved plan in the case all wor. � uire evi approval of plans.
SIGNATURE OF APPLICANT ...� PR1NT NAME �.�ol /Yf�t �{��% DATE �"e� [— I f
APPROVAL INSPECTOR SIGNATf�