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Building BUILDING
Inspections Pern,�t No.:_
763-572-3604 RESIDENTIAL APPLICATION Received By:
763-502-4977 FAX CITy OF FRIDLEY Date Rec'd�
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�rr�CCiVE 11-20ll �
DATE /�"'� ��' l� YOUR E-MAIL ADDRESS Ttti�n <,�.,:,C - v
SITEADDRESS �S65/ 7 �'�� `�r w��r� � - G�„k
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THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
❑ OWNER $�NTRACTOR
/e., �
aDD1�SS: /S�y •�S�` a4�� !v�
PHONE: CITY,
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ATE � /� ZIP Sf t(,?�
NAME: �:r1 �'v,erta / G✓ i-C'�at�.3 � �
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STATE LICENSE #� (� 3 SU ��'J LEAD CERT NUMBER 1�� ��
ADDRESS: 7(o/O C � `� ����:_r�ia� ���5°"
�__�nC�c � �„� ,S' �jvp CITY_f�:G sl��e.�.� STATE /�9NZIP SS-�/�
PHON _ �'S(�o(�-oL ��� FAX G/� - Frv !�+
oINGLE FAMILY/NEW CONSTRUCTlON SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ BASEMENT FINISH �vL,Uf tLL
O DECK �OF
SIDING
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ SWIMMING POOL
�AINTENANCE/REPAIR � ADDITION
❑ REMODELING
DESCRIBE WORK BEING DONE: /Q c,da„"r y,�/Gf � s�f,� ���
SIZE OF IMPROVEMEN7' LENGTH
ROOFING WIDTH
NUMBER OF SQUARES � HOUSE ONLY
❑ HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
❑ DRAIN TILE
❑ OTHER
BASEMENT REMODELING SUBMIT
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
SIDING
❑ Vinyl FOR NEW CONSTRUCTION INCLUDING DECKS,
OSoffit SIDING/SOFFIT/FASCIA A.DDITIONS & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES O IYO �• Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
WINDOWS 2. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS 3 Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROVIDE U-VALUE AND
OPENING CHANGES & MANUFACTURE STTCKER ON WINDpW.
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 VALUATION � /�..e�'� _ _ _
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� � ���_ See Back Page for Fee Schedule
$ —�-- 65% of Building Permit Fee
$ �� d .001 times the total job valuation
$ • v .0005 x Permit Valuation Minimum $5.00
�zs o $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 ( )
-$ ��. �-� C� Make checks payable to• City of Fridley Attach
THIS IS AN APPLICATION 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 wil] 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 �n the case of all wor ic requires review and approval of pian�S .
SIGNATURE OF APPLICANT PRINT NAME�'/'G
APPROVAL INSPECTOR SIGNATU �'� r`t �-� DATE /� v�.1''(/
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