P - 45472Building
Inspections
763-572-3604
763-502-4977 FAX
DATE
SITE ADDRESS
THIS APPLICANT [S:
_�
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
YOUR E-MAIL ADDRESS
PROPERTY OWNER/ NAME: ,/''/�. �/'/�.�,
TENANT qDDRESS:1G%�-`�.��,,�!/{!��
PHONE: � E> .�l � % I ' �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
NAME: d7(?�C�E�f�%✓.�i/ C�/C'�.-�j�6�C//C..�Y"
STATE LICENSE # c�� ita,3 r'�i��� ;,�-�, LEAD CERT NLIMBER
ADDRES��� �✓L.� / �.,,-'/''�� C`�-{_' /f'� �' � CITY,�
PHON��-��• � �� � (�' , �;_ �('� FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
Q ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDiNG ❑ OTHER
❑ SWIMM[NG POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
'gd�IAINTENANCE/REPAIR ❑ REMODELING
� -�L� . .',..�'i�J�L.0 d�c:.�'-']-v
�.
ROOFING ` �
NUMBER OF SQUARES I/ `�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SID[NG �
❑ Vinyt
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WTNDOW TO BE INSTALLED_
�OUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
OF
HEIGHT
Permit N
Received By: l�'� � '
�e� ��d'
TA
A'
FT
BASEMENT REMODELING SUBMIT:
l. Exis[ing Fioor Plan
2. Proposed floor plan
3. List of structural members to be used
��
FOR NEW CONSTRUCTION fNCLUDiNG DECKS,
ADDITIONS. Bc PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two seks 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:
(USI� THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $���,"-"� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
�$ �� L�j See Back Page for Fee Schedule
$ �— 65% of Bailding 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 ( )
$ Q .., Make checks pavable to: Citv of Fridlev Attach Stiaulations
THIS IS AN APPLICATION fiOR 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 c des 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 p it nd work " not to start without a permit on ' e; that the work wilt be in accordance with the
approved plan in the ca e work ic requires r iew and approval of pJ�ns. P/_ ���r//
SIGNATURE OF A.PPLIC PRINT NAMF�✓ r/� ),Q ATE
APPROVAL INSPECTOR SI TUR