P - 41201Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE ]-l-2011
Permit No.: �! � ^`-'�
Received By:
Date Rec'd: � � l.
DATE �I �;2 '� I:2.✓ i+ YOUR E-1v1A1L ADDRESS Jf.� vJ �E�Q►!� S�At CdY+�u�s ry �-.Q.�
SITE A.DDRESS [� (� [�`7 � C ����liN'� �-- L� ° � �- � n �'�-c-f . Nin N
THIS APPLICANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SU$MIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
,t L t. �M /�
ADDRESS: (D L� �� CE�e�N%�=�- �-�! C(TY
PHONE: 7Ln S �� � (Ca - � v �'�-1
STATE LIC£NSE #
CERT NUMBER
ATE M 1� ZIP � S,
ADDRESS: CiTY STATE ZIP
�1NGLE FAMILY/NEW CONSTRUCTION
TWO FAMTLY/NEW CONSTRUCTION
PERMIT TYPE � �DITION ❑ GARAGE/SHED
❑ BASEMENT FINISH �ROOF
❑ DECK �1 SIDING
❑ SWIMMING POOL
FAX
SIZE �(�
STORIES
'�WINDOWS
❑ DRA1N TILE
❑ OTHER
TYPE OF WORK: l❑ NEW HOME CONSTRUCTION ❑ ADDITION
I �'MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUM$ER OF SQUARES `� 0
❑ HOUSE ONLY
�,HOUSE & GARAGE
GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DE ACHED GARAGE
PROPOSED HETGHT: / _ � ` �� V ��V � `ZS�� �
SIDING �N � �^ �
❑ Vinyl 'S� � C.l� ❑Soffit � ,..�'L��
❑ Aluminum ; D Trim �
❑ Other ❑ Fascia
WINDOWS 2 5� � � �'
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS � S��
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
HEIGHT
FT II�1O1
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor p)an
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDTNG DECKS,
ADD1TtONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVtDE 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)
COTAL JOB VALUATION $ �5—�' 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
$ 7. 'L �
$
$ .
$ .�
$
$
$
$
$
$ �_
$
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 aavable to: Citv of Fridlev
Attach
THIS IS AN APPLlCATION 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 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 i not to without a permit on site; that the work will be in accordance with the
approved plan in the case of all rk hi, r uir revie a a roval of pl ns. �^ A
SIGNATURE OF APPLiCANT - fNT%�AME �6� L'n � JCls42ti DATE /�"2� I Zd l�
APPROVAL INSPECTOR SIGNATURE /�%U/,/� _ _ _ _ _ _ _ _
2 � 'Z 2 V