P - 47809Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT
Permit No.:
Received By: � �
����e+�'�+� � � � ��
� IVE i-I-2011
DATE_ '� � - l �
t� YOUR E-MAIL ADDRESS _C.e. u I Q c� pr�G ,,,,, � �� , G p�1
SITE ADDRESS �'r ��� 7 S y`rzef %7 /^
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:
❑ OWNER jaCONTRACTOR
NAME:
er
ADDRESS:� % '3 / % f%r S �i. 'i %%F CITY_ � � d Ie V
PHONE? 6 3- ,� � _ //sc� -��" STATF,�_ZIP "� �2
NAME:_ J lgeil S�r� �OnSf✓'4 �ion
STATE LiCENSE # L% 7�% 0 LEAD CERT NUMBER
ADDRESS:__ .7 2'� (� � n r�
n°""' �L. � CITY s f Lpy� ig /�tr�TATFI�ZIPs�y�
PHONE Z" Z - Q 7 FAX S Z- S 2 1�� S/ %�
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
�MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
SIZE OF IMPRnvFnnG�.�T
Qa ROOF
❑ SIDING
❑ SWIMMING POOL
SIZE
STORIES
❑ ADDITION
❑ REMODELING
��e- O � I ,r
❑ DRAIN T1LE
❑ OTHER
- "�'� � ^ HEIGHT � S FT
ROOFING � HOUSE ONLY
NUMBER OF SQUARES f� . 3 3 ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
GARAGES ❑ ATTACHED GARAGE 1 Existing Floor Plan
PROPOSED SIZE: ❑ DETACHED GARAGE 2 P�oposed floor plan
PROPOSED HEIGHT: 3. List of structural members to be used
SIDING
❑ Vinyl FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Aluminum �O�t ADDITIONS & PORCHES SUBMIT:
❑ Other ❑ Trim l. Site Plan/Survey showing the existing structures
I�"Fascia and proposed project.
WINDOWS . 2. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WiNDOWS 3� Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROVIDE U-VALUE AND
OPENING CHANGES & MANUFACTURE STICKER ON WINDOW.
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)
TOTAL JOB VALUATION $,�l �/,S' ,p ,p p
I Perm�t Fee OCCUPANCY TYPF
m _
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota! Due
'� '�'` • G-7 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ , 7� L, $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 a able to: Cit of Fridle Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED ' M.Y`.v„J
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 ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that 1 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 ork which�u'res review and approval of plans.
SIGNATURE OF APPLICANT
APPROVAL [NSPECTOR SIGNATURE PRiNT NAME_ Cra .s �q � DATE_� ^�/�_
�
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