P - 35258Building
Inspections
763-572-3604
763-502-4977 FAX
DATE_,�-" � �- �
SITE ADDRESS � S� �
THIS APPLICANT IS:
ERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS
%li �F'{� Dn� /�'� ��-
❑ OWNER �NTRACTOR
NAME: Lt /LrLf J Z �/2..
ADDRESS: ZS�XI ,Lgrt:��o'�.% � ITY
DLIlIU�• �%�n � / X � � � X �' i..� , �
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Permit No.: �a b �,� %
R ceivg� �y � ,�
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ec'd:
TF/�ZIP
�..ut� i x��. i vic NAME: - -- - - --- - • -- - - -
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE,_ZIP
.
INSURANCE runNF .... . . _ ....... �....., FAX _
PROPERTY TYPE
PERMIT TYPE
OF WORK:
SINGLE FAMILY/NE4V CCTIVS7'iiiiC'f[C71�i ""'�" SIZE
TWO FAMILY/NEW CONSTRUCTIOIV STORIES
❑ ADDITTON
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
NUMB R OF SQUARES 3Z.
GARAG�S
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
J�ROOF ❑ DRAIN TILE
O SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
0 HOUSE ONLY
O HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
O Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF
�_ (USING THE 1997 U.B.0 FEE SCHEDULE)
'O'I'AL JOB VALL
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Contxol
Park Fee
Sewer Main Charge
FT
�ASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMTT:
L Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Ca(culations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ANCY
AND MA
$ ' � I• 2-'S See Back Page for Fee Schedule
$ 65% of $uilding 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 (Ptans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
� . Make checks pavable to: Cit.y of Fridley A_ltac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowiedge that the information above is complete and accurate; that the work will be in
conformance with the ordinances d cod of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application r pe �t and work is not to start without a permit on si e; that the work will be in accordance with the
approved plan in the case of a ' s r 'ew and approval of play(�, / ,p -7��^ ��
SIGNATURE OF APPLICANT PRINT NAME /v°��'°�R/'��✓r✓ DATE