P - 37246Buildirtg BUILDING Permit No.Z�(� - Q((p(`1
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604
763-502-4977 FAX CITY OF FRIDLEY Date Rec'd: � L
EFFECT[VE 1-1-2011
DATE k�/ �J YOUR E-MAIL ADDFtESS C. ��-c I�'�i�r� �" � cz v� C.� CJ �' , L pr�
SITE ADDRESS �� %/ C E?d'1 / ✓'ct / l.�Cr�t �e k � �
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
❑ OWNER
NAME:_
ADDRESS
I�CONTRACTOR
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PHONE: `7 Lo 3 �" S %�7 — �'i �2 �) °�-
c. � 7���7
�"'r'� ���ti'y STATE�II%%ZIP ,�'$�'
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STATE LICENSE # �^7 % yD LEAD CERT NUMBER
ADDRESS: ��- 3 O �*� p�- {� cx �-`•—• �i +'/ �G' CITY S-F"• L F> c,r rs � STATF�ZIP ���
PHONE �S_ Z— % Z� �' a%/ 7 FAX �' S Z�- / Z9' -- R� 7 Z
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH � ROOF
❑ DECK ❑ SIDiNG
❑ SWIMMING POOL
SIZE
' TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
' ❑ MAINTENANCE/REPAIR ❑ REMODELING
�I DESCRtBE WORK BEING DONE: �c G" d% Y' ��- r" C7c>
I SIZE OF [MPROVEMENT LENGTH WIDTH
' ROOFING � HOUSE ONLY
I NUMBER OF SQUARES � I � HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
' SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXJSTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
Q Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
L Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WTNDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
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
Total Due
$ �5 . ��
$
$ � , o
$ .
$ ��O
$
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
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 code 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 a d w k is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of al ork which i review and approval of pla s. j'' Q� /' �
SIGNATURE OF APPLICANT PRINT NAME � f ci r� L u� DATE v/� �
APPROVAL INSPECTOR SIGNATURE '
�s� �/