P - 45779Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
Permit No
Received By: 3 �
D�lb�c�:� � ��
DATE �"Z,� '`r YOUR E-MAIL ADDRESS L� ricY �j��_
SI7'E ADDRESS ��C� ('��y �, ,� , 1 Q b�Q
THIS APPLICANT IS: ❑ OWNER �1CONTRACTOR
PROPERTY OW1vER/ N�E: � j, �`�,�� a �' Cby( ,J
TENANT qDDRESS:_ �.Q(p'ZC7 f" �nu..�.,e_( tIZ.C� CITY ���c�+-� STATE Mf�%ZIP �-rj�3�
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
NAME:
T
STATE LICENSE # �O�o 30� 33 LEAD CERT NUMBER
ADDRESS: r�o2�IlP �'�{�'Mhi�} S"T� CITY ���k ��`�'`�� STATE/YrV ZIP 5.�,�j0
PHONE � tv 3" � 3$` �o `'ta �I FAX 'i (e 3' 02 %�I "' � CI % 1�
STNGLE FAMILY/NEW CONSTRUCT]ON
TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT F[NiSH E�-R60F
❑ DECK ❑ SIDING
❑ SWIMMING POOL
STORIES 1
❑ WINDOWS
� DRAIN TILE
❑ OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�i MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �bo�
SIZE OF [MPROVEMENT � LENGTH "2(a WiDTH
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES _�� ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
I WINDOWS
!, IN EXISTING OPENINGS ❑Yes ❑No
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
! TYPE OF WINDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Softit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
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
l. Site Plan/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.
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
$ 7��� �)
$
$ �t;
$ Q�
$ U�
$
$
$
$
$ —��
$ "I 1.�_
See Back Page for Fee Schedule
65% of Buiiding 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= $
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: Citv of Fridlev
Attach Stipulations
THIS IS AN APPL[CATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
1 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 ity of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a e i ork is not to start without a permit o ite; that the work will be in accordance with the
approved plan in the case of all rk res review and approval of pl / / l
SIGNATURE OF APPLICANT PRINT NAME ��1 cGiCS DATE !O ����//
APPROVAL INSPECTOR SIGNAT