P - 48455.�uilding
` Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:
Received By:�
Date Rec'd: �
DATE 7�$�/�O/� YOURE-MAILADDRESS /`j�.f ��c�. /'')arce,� � �����v�,�.�
SITE ADDRESS S 7 3 3< n�1 c�� jj f /�/ E �� r o�,�P7 p��t..- s"S s/ 3�.
TH[S APPLICANT IS: �OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: /
TENANT ,e,DDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
��- rles`r�
PHONE: 1�.?'�/ - 3 3 / � � � � �
r �
oc
CITY �r�rl �e�� STATE MN ZIP �l y 3'�.
LCL_
STATE LICENSE #� �(p �C7%+ �j f LEAD CERT NLIMBER�T-, �o yfi - 1"J - l
ADDRESS: 7,��"�' ,t�Gt�r � � �� < %�r CITY �'a# ��''�.E.�,,.t STATE �! ?�ZIP '�Si ;� 7
PHONE £ts ;>6 ° r�� 4►Cr° ! �Cc�`'� FAX
�INGLE FAMTLY/NEW CONSTRUCTION SIZE_
❑ TWO FAMILY/NEW CONSTRUCTION STORI!
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED �WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK � SIDiNG ❑ OTHER
❑ SWIMMING POOL
TY.PE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OP SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�'MAINTENANCE/REPAIR ❑ REMODELING
r � .�.►� �e pl �- (S i ,•, �n � �,
E:� +k".df` �v,n acc�"�cn '� r ,
i FN(:TH . � . WTilTF7 �wC..� ��
WINDOWS
IN EXISTING OPENINGS �S%es �No
OR FOR NEW OPENiNGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WiNDOW TO BE INSTALLED t�r
ALL FEES ARE BASED
COTAL JOB VALUATION !
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Gontrol
Park Fee
Sewer Main Charge
Total Due
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
�a C� r�.n it �t'
SS'
JI `de NUMBER OF WINDOWS�_
Z �� SO FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDiNG DECKS,
ADDITIONS & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(LTSING THE 1997 U.B.0 FEE SCHEDULE)
OCCUPANCY TYPE
$ ��g''� ,�L, 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: City of Fridley Attach Sti
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pertnit 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 a work w ch �quires review and approval of plans.
SIGNATURE OF APPLiCANTp��•��.:!'� PRINT NAME ,/`�I� f��»- ��rt� � DATE��� �
APPROVAL INSPECTOR SIGNATURE _
M
■ .__.._.. _.y ........... . . ..._._...
�
`-�' �, �. Z^ � t�'z!M l
C�.CS Zx ��
�
� �* ,� .�
t�,� � �4 �� '�
t
�
� � �Z 1/
...�.��— ✓l �v�� � 1 9
��,Cc� z. i�-S ��► 20� -;�
� ��
1��� . � � �
� � s� �����
� �� ��
�� �
4 �
.."`��
�\ � 1f `l I�) �` �,,.. ��. l.. � � , � —
f�
�
. .. , . ____.._ . .
_ ��_..._..T._.� �:.�_.
`° ._ _._.___.__.._.., .� ,.. ._,�__,____
___.�.__-M._____.._..._.___... _ �j%j; � _ -..___ _�. _ ._. _r._.__
CODE �OMPI�ANCE
����
; � , �� r;:a , . , ;' ; �. . •" t.,
e
a � � ,, �.r :; .;.,
�..+
F
L��� �� �
..�.,_._.._._..� �
��
%
� LL
r�
`.,`.'.�„_
� d"
-