P - 36747Building
Inspections
763-572-3604
763-502-4977 FAX
DATE y`{Lt (D �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTtVE 1-1-2011
Permit No.: ���1 Y"U 1 �,��,/
Received By: . �
� . �, � ;' ,,y
: '.
YOUR E-MAIL ADDi2ESS 1lJ�O �i6 J�N�(�F.Q �rq..,(� Etf-�t�' � V�R.S CL7�1
�a2 N �i '"
� OWNER �CONTRACTOR
NAME: LURV � �. .� � � .M.n^ V �J
ADDRESS•. fp�I t5 ,��2,,o Kv�e �,J DQ+�.cr-rv
PHONE: � �'��i�? ( ` �f51 Z-
ATE {D �aJ ZIP
NAME: � \�M131�2\d4Y�.� ��'t'flZCf/�Z.j
STATE LICENSE # �LU�-f� Zl �-E S E�EAD CERT NUMBER
ADDRESS:aOi �+46�E. �-�'�� CITY.S��\��,�-, STATE ZIP
PHONE (n51-�F39 " ���'� FAx
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION S[ZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH � ROOF ❑ DRAJN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITiON
O MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES � �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
' SIDING
! ❑ Vinyl
❑ Alumittum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHBD GARAGE
❑Soffit
O Trim
� Fascia
WINDOWS
1N EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2: Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION (NCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I, Site Pian/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WiNDOW TO BE MSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota1 Due
. �.
d
���
I.'�:�1L .
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 + 6 ft= ft x$25= $T
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the inforrr►ation 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 appticati for a permit and ork is not to start without a permit on site; that the work will be in accordance with the
approved pla,n in the cas f I w rk whic review and approval of p s. �� O,�`
SIGNATURE OF APPLICANT PRiNT NAME �l �Itdt'L�,� Il�frvkJ DATE
APPROVAL INSPECTOR SIG URE