P - 36751Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � " % I � !
SITE ADDRESS �
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
/
BUILDING
Permit No.: L-�
RESIDENTIAL APPLICATION Received By��'�'
CITY OF FRIDLEY Dat����'d ����
EFFECTIVE 1-I-2011
YOUR E-MA1L ADDRESS GC' 4/ � � p/`{7G �-, ct vc.' . GO �'�—�
✓'G`i C %/I �
❑ OWNER I�CONTRACTOR
NAME: �/! 2 c;, h-P 77i i� t� /' �J 7%�
ADDRESS: 'J'' 3 6 `7 /L% % f u ✓ 4 �a% ��CITY �✓'� �
PHONE:� J" 5� 72� Gj �/� �/
NAME: J�5 �� S.� 01 L a�
STATE �� ZIP .�SyZ�
STATE LICENSE # U 7 yD LEAD CERT NUMBER
ADDRESS: �2 30 �D/'�p.�y /.�v� CITYS7�•Lp�rs%�r� STAT�ZIPS� 2
ea�N� '�� �L" S`� S-771 G
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH fjd ROOF
❑ DECK ❑ STDTNG
❑ SWIMMING POOL
FAx 9 �Z-
SIZE
STORIES
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�1 MAINTENANCE/REPAIR ,� REMOQELING
iDESCRIBE WORK BEING DONE: /'�� r� E 0 E-' �¢
I SIZE OF IMPROVEMENT LENGTH WiDTH
ROOFING � HOUSE ONLY
I NUMBER OF SQUARES � 2 � HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
' SIDING
O Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS �Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENIIJG CHANGES &
TYPE OF WINbOW TO BE iNSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
O Fascia
LOCATION OF W(NDOWS
NUMBER OF
O DRAIN TILE
❑ OTHER
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDINGbECKS,
ADDITIONS. & PORCHES SUBMiT:
1. Site Plan/Survey showing ffie existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculazions
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
— ---- _— _ — - _
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION S OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
11;/
—,
����iL
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 SAG Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: Citv of Fridlev 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 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 the case of al ork which/ �qui� s review and approval of pl s. � �y JI
SIGNATURE OF APPLICANT �_ z:,s�..l' PR1NT NAME �✓ a� o� � N/ DATE Q"�%' !/
APPROVAL INSPECTOR SIGNATU�