P - 46717Building
Inspections
763-572-3604
763-502-4977 FAX
DATE Y I
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERNIIT TYPE
�
BUILDING � 4�}t t�ln��'�`�
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
iT�i.�7
YOUR E-MAIL ADDRESS
Permit No.:`2-� � � �
Received By:
Date �'�: r� � i 1 �.�
NaME: K � m �-2 ►� N l�
ADDRESS: �J� �J1 C. �P Gl.l"�%� e� CITY `� 1� 1 C'� �� v_
Pxo1•rE: '7 (�3 - �}y- 3-� Sa �7 `�
NAME: rT�.4bbC' ��r'15'M�IC�`R.CS`�. I N�--.
sTA� i.rc�vsqE a Bc - a�a I F� �aCi LFan c�T rruM
ADi�RF.SC- 1��} I �I r-P l�% l� GlU1 R 1 LX'O CITY
PHONE %S� � �'4'
PfiSINGLE FAMILY/NEW CONSTRUCTION
� TWO FAMILYlNEW CONSTRUCTION
❑ BASEMENT FIAIISI-I �hOOF
❑ DECK ❑ SIDING
F� (nS l - `I
SIZE
STORIES
o wtrrnows
❑ DRAIN TILE
C7 OTHER
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ ADDITION
,�SCMAINTENANCE/REPAIR ❑ REMOpELING
DESCRIBE WORK BEING DONE: �e I'Y�v�'� -r i2,e p a-� e cSh �►-� q e s C7'C�
SIZE OF IIviPROVEMENT LINGTH WIDTH
ROOFING TQtrr�- ❑ HOUSE ONLY > j� S� S+ �)
NUMBER OF SQUARES ��, � �iOUSE � ^-".� D��-
GARAGES
PROPOSED SIZE:
PROPQSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
❑ (hher
❑ ATTACf�D GARAGE � Q � �, ��
^�DETACHED GARAGE �
:�
HEIGHT
qa
�•
1. Existing Floor Pl�
2. Ptoposed floor plan
3. List of structutal members to be used
--'--" FOR NEW CONSTRUCTION INCLUDING DECKS,
❑SoffiY l (p ,�j S� '7� �� �DITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing sVucUire,s
❑ Fascia �d Proposed pro�t_
2. Two sets of construction plaes
WINDOWS 3. Energy CalculaUOns
IN EX[STING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PRQVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICK$R ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALSt
(LJSING 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
$ $� 1� Z� See Back Page %r Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuarion
$ � .0005 x Permit Valuarion 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
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acirnowledge 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
pernut but only an application for 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 of 1 work which requires review pproval of plans.
SIGNATURE OF APPLICATI�'��,�CtT.� �_� RINT NAME 2� �-r �n1 M• ti�1�ATE � �� Il., I 1 I
APPROVAL INSPECTOR SIGNA