P - 45742Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLE�
EFFECTIVE 1-1-2011
Permit No.;
Received By� � �
�
Date Rec'd:12 %
DATE C9' 3O'- �� YOUR E-MAIL ADDRESS P c.7�v.7+G'To.�H ��p /_ c.G.�
SITE ADDRES3 �e %U� GLic-c,�/l,L � �'`cI. ��t.
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
❑ OWNER
L ���
�ONTRACTOR
c��,/'
ADDRESS: �7UU C C«."�e � G�L�i, ,�L/S CITY `��'.�/e.� STATE M""LIP
PHONE: G/2 — �7d'.- t/�/�G
NAME: P'/<p I7o.s, e Je�-.v,
STATE LICENSE #�' G G 3 2�iC1 �.3 LEAD CERT NUMBER
ADDRESS: �r-s .i ,3.�0C� .�a.� S�: �,1-{.2c`S6 c_ac,.., .!� A � t�
� CITY �' �z • 5 STATE��ZIP.S�`��i
PHONE �� 2, .2 t/ Z.. �7 3�% FAX � C.� - 3 2 3_. y�Q L�
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
I,g MAINTENANCE/[tEPAIR
� ROOF
❑ SIDING
❑ SWIMMING POOL
SIZE
❑ ADD[TION
❑ REMODE(,ING
� WINDOWS
❑ DRAIN TILE
� OTHER
�j uo � �, c � � � ,t 7.��, �✓�
...,� /
DESCRIBE WORKBEINGDONE/�c. %Lc,v� /5.'Jc c7-� �{�rac lLe,o!<.� S� c��c.c K���J.� /���`� e y°i��✓�•�� _�" � 2��°` ^
�. S'��c� 2tPS.;. �
SIZE OF [MPROVEMENT
ROOFING /
NUMBER OF SQUARES (�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
D Vinyl
� Aluminum
�'Other S �w� ,/t.��s.`�
WINDOWS
IN EXISTING OPENMGS I�Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED i+/cx+r�
�CHOUSEONLY �r2 a� /2���-
❑ HOUSE & GARAGE
Q ATTACHED GARAGE
❑ DETACHED GARAGE
OSoffit
❑ Trim
❑ Fascia
�Cir1� 0� I'Uh s.
LOCATION OF WINDOWS
2��,�,. 1 G., �/ 2 uts14, s
�y�w`^� NUMBER OF
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
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 $ f,�, bU� 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
� I 5 tx�
$ `{ ��
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Pennit 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 Rev�ew
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks aavable to: Citv of Fridlev
Attach Stipulations
THIS [S AN APPLICATION FOR A PERMIT-NOT VAL1D 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 is not start without a permit on site; that the work will be in accordance with the
approved plan in the case of all work which r ' es review d appr 1 of plans. /�
SIGNATURE OF APPLICANT PR NAME �d/r1 Ir✓{� DATE �—,,�r>— ��
APPROVAL INSPECTOR SIGN E / i / .x.,. , i