P - 35054Building
Inspections
763-572-3604
763-502-4977 FAX
DATE___ ��LJ/Y/
SITE ADD S�
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
_ EFFECTIVE 1-1-2011
�vo� s T
❑ OWNER
S
Permit No ��V � �b � ��
Received By:
D��e� � ti ,�_
YOUR E-MAIL ADDRESS /rV �r� �,%%i(/ Jc��(/lwt.. C�,� �L/2/ O�LS ,1�.�.
�i2> GL=�,
PHONE: �%/e_5' � �%�Q� � �� �/ S^
� s T CITY
CONTRACTOR NAME: �N _ c�t�.w• r'zx %`�
SUBMIT A COPY OF STATE LICENSE #_�Q� j9 � j�Q
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: /��gG' /�•¢�/�`�'z CZ�.�
INSURANCE PH(�NF % C~/ - i`� � r_ G' t' Y"
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ATFJ%is�/ ZIP
LEAD CERT NUMBER
CITY „�J/ � STATE�ZIR�s/.� C7
FAX (��/ " /7t!—
SIZE
STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH 6�ROOF ❑ DRAIN TILE
❑ DECK OSIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION � ADDITION
❑ MAfNTENANCE/REPAlR J� REMODELING
.. ✓''�.G �` /LaLC/
ROOFING ^
NUMBER OF SQUARES �_��' �i�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
�
� Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
� HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
OF WINDOWS
BASEMENT REMODELING SUBMIT•
1. Existing Floor Plan
2. Proposed floor plan
3. List of structurai members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT•
1. Site Plan/Survey showing the existing s[ructures
and proposed project.
2. Two sets of conswction plans
3. Energy Calculations
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. FEE CHEDULE)
COTAL JOB VALUATION $ /�`ao ��0� = 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
$ ' " • �Z�
—$ �.--
$ �3
$ i.-I (p ��
$ S � �'
$
$
$
$
$
$ ' ��
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$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: Citv of Fridlev Attach
lations
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 �11�j'or�; h�ich requ s review and approval of pl nsy
SIGNATURE OF APPLICANT lit/.iGGfi� i!%�� PRINT NAME �I/I {� �'!T ryL �-�P/1£� DATE al�Y/��
APPROVAL INSPECTOR SIGNATURE �