P - 47781Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 1D - � ' � (
SITE ADDRESS � ]._ S �!�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
�
�
NAME: -) 6
ADDRESS:
PHONE: �r
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
_ EFFECTIVE 1-1-2011
Permit No.:
Received By:
:::. , � � �
YOUR E-MAIL ADDRESS (��G� L('+� {'l�.(,(� X-�p^1 pd .(��iYY�
.` tif.. _ _ .,�
CITY
TATE �( ZIP S S�� Z
NAME: � �.�.�V'I S �,�(X` . _
STATE LICENSE # pZ.�S�73� % LEAD CERT NUMBER
ADDRESS: IO�Q� � � �((� �(J , CITY , � (94Cr(�� STATE /�WZIP .,� 5��(,
PHONE �3 ' �S- �SC1� FAX nQ3 '�fS- � C7
�a-�iNULr; raMn v.�rvEVy CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STOF
u rivvt i ivtv ❑ GARAG
❑ BASEMENT FINISH �TtOOF
❑ DECK ❑ SIDING
IJ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: 1� C�� - %�e rC7�,�
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING �HOUSE ONLY - B�' �n �/
NUMBER OF SQUARES �. � ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ Aluminum
O Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
O Trim
❑ Fascia
❑ DRAIN TILE
❑ OTHER
HEIGHT
FT
BASEME"T R6MODELING S[JBMIT�
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT:
L Site Plan/Survey showing the existing structures
and proposed project.
WINDOWS Z. 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-VAI,UE AND
OPENING CHANGES & MANUFACTURE STICKF,R 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�T�IE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ t.��C� —
� nr�i ro �,vr� T�,.,..
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
I hereby apply for a building p�
conformance with the ordinances
permit but only an application fc
approved plan in the case of allyy!!
SIGNATURE OF APPLICANT __T���
APPROVAL INSPECTOR SIGNA
PLEASE NOTE: SEPAR
$ :j1�"•,1—,� m
_$
$
$ :.l � .•
$ �� (;
$
$
$
$ _ _., `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 Stipulations
TH1S 1S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
�it nd I ack wle e that the information above is complete and accurate; that the work will be in
de e i of Fridley and with the Minnesota Construction Codes; that I understand this is not a
pe ' and is not to start without a permit on site; that the work will be in accordance with the
i re i d approval of plan�}-�� �- /' /�
PRINT NAME (}//�Q �„SS DATE_ (p ^% °//
�>'L
FOR