P - 48007Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�' L� %�L�l
SITE ADDRESS ��(��
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTTFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE I1-2011
� OWNER
NAME: C}�.V
ADDRESS:�
PHONE: -� 6
NAME: r'
STATE LICENSE #
ADDRESS: �� t_�
YOU1R E-�vIAIL ADDRESS /I/Qur���.��,��
, �v� ��-e::� 11��t u � � �
)NTRACTOR
�OV,-l�.
> 7�� � h U�v e vr Ls CITY �^� � �
�l � S q (, s
�� e^ce^1' � �,� s,t o`�' �o w�t fn r�: i
PHONE U�`Z. `� /i 1 C�S T/
fdCSINGLE FAMILY/NEW CONSTRUC U
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH O ROOF
❑ DECK .PR STnTN
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
0
o�HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
O DETACHED GARAGE
��� Fa
SIZE
STO1
HED
iPOOL
ADDITION
REMODELING
Permit No.: Z, � � � ��J�
Received By:�,� —_
Dat���'� � � !� � Z A i
TE�ti(ZIP
l�J�����
CERT NUMBER EXP:
CITY / �(d�-�% �'l� V� STATE U�' �'1�IP
x � b � �_�7 �-i "I 0.� 2-I
❑ DRAIN TILE
❑ OTHER
l�i�l[ti:�'1
FT
BASEMENT REMODELING SUBMIT
1. Existing Floor Plan
2. Proposed floor p(an
3. List of structural members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vin 1 ADDITIONS, & PORCHES SUBMIT
Y �Soffit SIDING/SOFFIT/FASCIA �, Site Plan/Surve showin the existin structures
❑ Aluminu ,�f Trim REMOVED? � YES ❑ NO Y g g
� Other �3�C ` ❑ Fascia 2. T o s s ofconst�ru tion plans
WINDOWS 3. Energy Calcutations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
['OTAL JOB VALUA'i'iniv Q � I�\� �i1-`� 11� ..�—
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ I `� I. Z5
$
$ �,�
$ ,�
$ u
_$
$
$
$
$
$ .
OCCUPANCY TYPE
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 payable to: Citv of Fridlev
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL 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 all work_which 'res review and approva) of play�s. , j� f/ Y
S[GNATURE OF APPLICANT ,�'''^�'J`'� _.,. PRINT NAME C c�-€�t � ,r �� `� DA� i 2� �/��
APPROVAL INSPECTOR SIGNATURE