P - 41783Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:
Received By:
Date Rec'd:
DATE �-��dZ. �j � �LD� I YOUR E-MAIL ADDFtESS (�JtC.� k�tU'`�j� ��C, m�l I� LC�`-�, y
SITE ADDRESS _�,Q ( 2 � iP � � U. ��•
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
NAME: � �h�'l i�. n l�it�l1'Z�1�
ADDRESS: � Z �' N-E- CiTY E�t 4�I c[r STATE�LIP
PHONE:
NAME:�Ii[I��. L,Pd.1 di � �
STATE LICENSE #____ �(`.b�t0 �I � y LEAD CERT NUMBER
ADDRESS: I�%Z �'�� %�t/'L CITY ST taa,,,�,I STATF/Z1_�LIP /O
PH NE FAX
GLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE o �DITioN ❑ G,viac
0 BASEMEIJT FINISH i�ROOF
❑ DECK ❑ SIDING
❑ SWIMM
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR O REMODELtNG
DESCRIBE WORK BEING DONE:�=
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Othec
WINDOWS
IN EXISTING OPENINGS ❑Yes �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
LOCATION OF WINDOWS
OF
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
HEIGHT
FT
BASEMENT REMODELMG 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:
1. Site Plan/Survey showing the existing swctures
and proposed project.
2. Two sets of conswction 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:
,�iJSIN THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �' Z� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charg
Total Due `l
$ �j�j. G��' See Back Page for Fee Schedu(e
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ 5c � $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 chectcs payable to: City of Fridley Attach
THIS IS AN API�LICATION 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 ork is to start without a permit on site; that the work will be in accordance with the
approved plan in the case wo��t rti ic r quire rev' w nd approval of} �lans.
SIGNATURE OF APPLICANT P iNT NAME u2v ��12C G� DATE ��"� .�_ I'2r�,/ !
APPROVAL INSPECTOR SIGNA E �/l. �, i�^�
� 5� �