P - 39364Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �Z � 7� z- � ��
SITE ADDRESS � yb 9
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MA1L ADDRESS
/�. r� S�trt f un L.� %% �
❑ OWNER �NTRACTOR
Permit No.:�� � '� �� �
Rece�ved B � � ° w
��'b ��
Date'7tec'd:
PROPERTY OW1vER/ NAME: J�� CJZZa l(
TENANT ,r�DRESS: �a yUcj C l�-✓�i hek soH L.ti N CfTY �'�c�( «� STATE l�-C�IP -��`�; �
PHONE: �Cx � - Z � t, -533 � —r
CONTRACTOR N,�g: i{�,,,,,� �„�,�, 2�� 1v��...1-.�
SUBMIT A COPY OF STATE LICENSE # � � � �
YOUR STATE LICENSE 4 3o S 3 / LEAD CERT NUMBER � .2$y - �
AND CERTIFICATE OF ADDRESS: �d(v �r G V•(Cc�.t a( � v CTTY W� Ut�� -�_STATE �d,V ZIP ��/L L
INSURANCE pHONE � G�—�/9 `/ '� 4 S i FAX
PROPERTY TYPE i�GLE FAMILY/NEW CONSTRUCTION
I ❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ �DITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK:
❑ GARAGE/SHED
�OOF
❑ SIDING
❑ SWIMMtNG POOL
S[ZE
STORIES
❑ WINDOWS
❑ DRAfN TILE
❑ OTHER
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: Irt— rb ��
ROOFING
NUMBER OF SQUARES a a
GARAGES
PROPOSED SiZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS �Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENMG CHANGES &
TYPE OF WiNDOW TO BE INSTALLED
�6USE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑5offit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Pian/Survey showing the existing structures
and proposed project.
2. Two sets of conswction 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)
COTAL JOB �ALUATION $ Co, dOV '`� 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
����
�:
�
_;,
����ii'.
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 pavable to: City of Fridley
Attach Stiputations
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 codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an apptication f r a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o ork •e ir review and approval of p�ns.
SIGNATURE OF APPLICANT PRiNT NAME J�.�c..'%ti.-�� Ich DATE �` %' Z a� �
APPROVAL INSPECTOR SIG RE