P - 48542�� �,
Building
Inspections
763-572-3604
�763-502-4977 FAX
DATE .� " G ' �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
��
BUILDING Permit N'o.: ��' � �-
RESIDENTIAL APPLICATION xe�eivedl,By�
CITY OF FRIDLEY D���'p�� °" ``" !��
EFFECTfVE 1-1-2011 �
0
NAME:
ADDRESS:
�7
YOUR E-MAIL
��
NAME: - IJZ�CS!
STATE LIC�EN(SE # �
ADDRESS: �--t � tJ✓'
PHONEIo.�� ! �`7� ���P
�SINGLE FAMILY N
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMMING PO�
�v�-c� �
EAD CERT NUMBEP
CIT
FAX �S� %
SIZE
STORIES
�GVINDOWS
❑ DRAIN TILE
❑ OTHER
� NEW HOME CONSTRUCTION ❑ ADDITION
B'S�4AINTENANCE/REPAIR ❑ REMODELING
n c, . � or�-,
TA
�
�
� u��— a-��c� — �
fI'AT� �IP ��C! �
, 'nl�c��
�
9�
DESCRIBE WORK BEING DONE:��A�Q�'1� �.�.�� ��(�C...GC.Q-(,(,(.p //Yt�� ,�i(��„j.� J
�S1ZE OF IMPROVEMENT V LENGTH WIDTH HEIGHT �, S F
FtOOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
y,NUMBER OF SQUARES ❑ HOU3E & GARAGE ]. Existing Floor Plan
GARAGES O ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: � DETACHED GARAGE 3. List of structural rrs'embers to be used
PROPOSED HEIGHT:
SIDING FOK NEW CONSTRUCTIONf 1NCLUDING DECKS,
ADDITIONS & PORCHES S�UBMIT:
❑ Vinyl OSoffit 1. Site Plan/Survey stjowing the existing structures
❑ Aluminum ❑ Trim and proposed projdct.
� Other ❑ Fascia 2, Two seu of construct�on plans
R'INDOR'S ,_,/ 3��� �,` 3. Energy Calculatioris
IN EXISTING OPENINGS ,�Y es ❑No LOCATION OF WINDO S '" � FOR WINDOWS — PROVID� U-VALL7E AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF � �V _ 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:
SING THE 1997 U.B.0 FEE 5CHEDULE)
TOTAL JOB VALUATION $�, � D� • oO OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
sLicense Surcharge
SAC Charge
Curb Cut Escrow
"Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ `'j�/, e� 5 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• D � $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination�
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( ) ',
$ / lr% . Make checks pavable to: Citv of Fridlev Attac
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; tl�at the work will be in
conformance with the ordinances an od�sv#'the City of Fridley and with the Minnesota Construction Codes; that I'�understand this is not a
permit but only an application for a pe it ar�d work ' not to start without a permit on site; t the work will be''lin accordance with the
approved plan in the case of r wh uires ie and pproval of plans�.1 h
SIGNATURE OF APPLICANT T NAME �J(�(, L� DATE ��Q� ' I�
APPROVAL INSPECTOR SIGNAN '
PLEASE NOTE: SEPARAT '� -E ITS ARE REQi7TR����(?R.P',LTJMRiNC'�_'Ei.F.C"'PRT('AI, ANT)�MF.('H-' �LT.C'AT:,�W1)RK �.