P - 35409Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ^I''" d'G?� �t,
SITE ADDRESS �
THIS APPLICANT IS:
�f
BUILDING Permit No.� °�--�/� 7
RESIDENTIAL APPLICATION Received By: �
��y�.
CITY OF FRIDLEY Date Re�'ct: ��
EFFECTIVE 1-i-2011
YOUR E-MAIL ADDEZESS S�^ `'�S U��/c.i% ('�C YtiS�fVe�.G �
�v;ew �r��z �c��l� � v�,� �.`;'-ti3'�--
� OWNER �'CONTRACTOR
PROPERTY OWNER/ NAME: ��I(e,I�-- G-�-rSG�
TENANT
ADDRESS: �0�`�a rSCfRi�(/iC�.✓ �1vti CITY �,�`.n )v„ STATE �� ZIP J���
PHONE: % 1p 3 5'1 � $ 3�-I �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND C�RTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
STATE LICENSE # �-G% 5 g'�Si� LEAD CERT NUMBER
ADDRESS: ��1I L{�{ 1Zacr�c,V�� S�"V� CITY t9aYh �� Q STATE�M�I ZIP�
PHONE __ ___ __ FAX
$I"SINGLE FAMILYMEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH C�7-ROOF ❑ DRAiN TILE
❑ DECK ❑ SIDTNG ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION O ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEiNG DONE: �Z� �OG�
ROOFING ��
NUMBER OF SQUARES
C�ARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SlDING
❑ Vinyl
O Aluminum
❑ Other
WiDTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
0 DETACHED GARAGE
BA3EMENT REMODELING SUBMIT:
1. Existing Fioor Plan
2, Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDING DECKS,
❑Soffit ADDITlONS. Be PORCHES SUBMIT:
❑ Trim l• Site Plan/Survey showing the existing suuctures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
M EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WMDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
` TYPE OF WINDOW i'O BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
fOTAL JOB VALUATION S
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
- �l�
i���'
��I(�°'rL'
ANCY
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Vafuation 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 uavabte to: Citv of Fridlev
_ Attach Sti
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL 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 cod s o the of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit an o is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all r hich re review and approval of pla s. / /
SIGNATURE OF APPLTCANT RTNT NAME ��r ��t �`�S � DATE S oZ6 - I(
APPROVAL INSPECTOR SIGNA �
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