P - 35782Building BUILDING Permit Ivo.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY nat� 'd: ��
763-502-4977 FAX EFFECTIVE 1-1-201I �
DATE � T� j�' �/ YOUR E-MAIL ADDRESS L� ,�f'1/�� f' � � G�X�er� u/' '�/O�'✓�
SITE ADDRESS S�A�U �l � S %UL•
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:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
❑ OWNER �CONTRACTOR
NAME: ��f �" cti�l.o_ %S 19 ril, v� a
ADDRESS: 5 b�
PHONE: 6�2 �
NAME: _�
STATE LICENSE #�
ADDRESS:�
PHONE �/ a
� CITY r ' STATF��ZIP_�L���
' d � Sor�/i'to�r`f'
��' �/� V v�. 11/� G l>>'✓1 �7��c�"i OY',�' c
� %� LEAD CERT NUMBER
% .��1 t/� ��/ CiTY_ �� �ai— STATE�✓1 ZIPS��lI
O1 /'1t � FAx
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH ,�[ROOF
❑ DECK � SIDING
� SWIM
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
ROOEING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIZE
STORfES
WINDOWS
❑ DRAIN TILE
❑ OTHER
MING POOL
❑ ADDITION
�REMODELING
^(j� �j f� O HOUSE ONLY
� J"\ `1� ❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
IDING
❑ Vinyl � ��� ❑Soffit
❑ Aluminutr� ❑ Trim
,� Other i GC�^'�t/� ❑ Fascia
WtDTH
WINDOWS
IN EXISTING OPENINGS �Yes ONo LOC�' ION F INDOWS � )
OR FOR NEW OPENINGS-DESCRIBE SIZE OF 1>l'dI'�� �'v�^O1 /l2C�'��'�`�'1(��
OPENING CHANGES & �v)1 �r�,vtti �'
TYPE OF WINDOW TO BE INSTALLED C� J�t�✓�o, NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VAL
CAL JOB VALUATION !
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
F7'
BASEMENT REMODELMG SUBMIT:
I. Existing Floor Plan
2. Proposed floor pian
3. List of structurai members to be used
FOR NEW CONSTRUCTION MCLUDING DECKS,
ADDITIONS. & PORCHES SU$MIT:
i. 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.
ATION, INCLUDING THE COST OF LABOR AND MATERIALS:
G THE 1997 U.B.0 FEE SCHEDULE)
�.P OCCUPANCY TYPE
.,
���
� ��
l_S
E�^..���1.
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
THIS [S 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 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 tt�e case of all rk �c�Q uir rev�ew and approval of plans. l y�% , 'i���—
SIGNATURE OF APPLICANT _,!//��� PRINT NAME ��� jG�G �1 /" '1� �I ry(,J DATE �y� � I I
APPROVAL INSPECTOR SIGNATURE