P - 35211Building
Inspections
763-572-3604
763-502-4977 FAX
DATE s�� ��-��� ��
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE ]-1-2011
Permit No.
Received By: �' �"" '
Date ��D . � !.1 � 2 � 20 �
YOUR E-MA[L ADD[2ESS �J�ibUS �� CQJ��'�IrQ.tLt�(J� C(J✓l �
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SITE AD RESS ��`�i�� �i�%�,:, ��� i: r-; r
TH[S APPLICANT [S: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUT2 STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
3- �.el�O i�c. L-P (�
ADDRESS: 6Ff �{O Q�dic v,°u/ D✓� �— CITY F'r rc(I� c�J STATE M N Z�p S
PHONE:� �(o� — S% 2" 2—� 2�
NAME: L.rnn S��r u �'C' i o-n Lo� V; O S
STATE LICENSE # 2--0 ���i 7O� LEAD CERT NL)MBER
ADDRESS: 2Z-'�J% f�j7irt\ ��e �t% CITY �n�OV� STATEM�I%ZIPSS3U
PHONE 7 6 3` S�'' g 3 s� FAX N/�
,�SINGLE FAMILY/NEW CONSTRUCT]ON SIZE �—'-f S�,
❑ TWO FAMILYMEW CONSTRUCTION STORIES �
❑ ADDITION ❑ GARAGE/SHED O WINDOWS
❑ BASEMENT FINISH ,�1cROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TY.PE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAfNTENANCE/REPAIR �.REMODEL
DESCRIBE WORK BEiNG
7ec. i/' ��- � P� �/Zlb � �° v O
ROOFING Z �
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
� Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
0 Pascia
WINDOWS
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS
OR FOR I�IEW OPENINGS-DESCRIBE SIZE OF
OPENIIJG CHANGES &
NUMBER
�'f'�'�t,�ed� ��,c., �✓�-�---
HEIGHT _ SQ FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction pfans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEE5 ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
P1an Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ .��
$ 1 �2�1
$-- J�(�
$
$
$
$
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= 8x$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks payable to: Citv of Fridley
Attach Stipulations
THIS IS AN APPLICATi�N FOR A PERMIT-NOT VAL1D LJNTIL 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 a wor w uires review and approval of pl�1s.
StGNATURE OF APPLiCANT __[I���� PRINT NAME_ I.SPnn �4'EOv()S Z DATE ?.!'J
APPROVAL II�ISPECTOR SIGNATURE