P - 35963Building BUILDING Permit No.:�-C� C��� ��`�
Inspections RESIDENTIAL APPLICATION Received By: ./�1,1
763-572-3604 CITY OF FRIDLEY �
763-502-4977 FAX ���+�e��
EFFECTIVE 1-1-2011
DATE r5 " �� � � YOUR E-MAIL ADDRESS —1 !�F"Y►' l�tf � � �c, a - C_���---
SITE ADDRESS ��O _%�� �P '
THIS APPLICANT IS: ❑ OWNER �7CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
ADDRESS: �lofl J 7�'� S� •/i1F �• CITY � �rci l e`l STATE Ni h
PHONE: �%G� "ZS�f — �0 3I D
NAME: �OfJ{ L�C�
STATE LICENSE # �
PH�3AIE ��O�S � �S'�a - � y�/
SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO PAMILYfNEW CONSTRUCTION
❑ ADDITION ❑ S'i�4RAGE/SHED
❑ BASEMENT FINiSH PfROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
SIZE
TYPE OF WORK: � I�i�W HOME CONSTRUCTION ❑ ADDITION
��AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �t6t/ O/�F �GS� ��
SIZE OF tMPROVEMENT LENGTH WIDTH
ROOFING � HOUSE ONLY
NUMBER OF SQUARES �� ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
i SIDING
❑ Vinyl
O Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS �Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
CERT NUMBER
CITY �-WIrZ,�WL STATF�vZIP S'�3?•
❑ WINDOWS
O DRAfN TILE
� OTFiER
BASEMENT REMODELING 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 structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS – PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF W[NDOW 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)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Swcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � i l• LS See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ (S $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Pian Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ ( d� Make checks payable to: City of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALiD UNTIL PROCESSED
I hereby apply for a building permit and 1 acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinanc d codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicati for it 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 al rk c uires review and approval of plans. ���,,[ �� �� ��
SIGNATURE OF APPLICAN PRINT NAM�/�'yM�1 J� /��"" DATE
APPROVAL [NSPECTOR S A RE —T