P - 35454Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECI'IVE 1-1-2011
Permit No.:
Received By:
�.,- r -'
DATE v t t 1 YOUR E-MAIL ADDRESS �� n'l Gt, Yt /,ri.,�t.. iC� �w�� YLLi /],� � i' �,�,,�J �
s�� nDn�ss � G' (�'c1 I �' (;i +� �/� {..t;� �j�- • 1`.J —r----
THIS APPLICANT IS: ❑ OWNER "'�CON'I'RACTOR
PROPERTY OWNER/
TENANT
coxT�cTOR
SUBMIT A COPY OF
YOUR STATE LICEN3E
AND CERTIFICATE OF
INSURANCE
' � � ' ifiZtf��i��1�'�►"�
. � , � ��
STATE LICENSE #
PROPERTY TYPE I�SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ ADDTTION ❑ G�c
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IlviPROVEMINT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
❑ BASEMENT FINIISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
❑ NEW HOME CONSTRUCTION
CITY�,. (Q. ti1 STATE N� �LIP SS�-(Z 9
LEAD CERT IVUMBER
Q�� � i t S crrx�}
Fn�c (l� l2- ' �
SIZE
STORIES
�✓s�n y�wn�rnows
❑ DRAIN TILE
❑ OTI-IER
[NG POOL
❑ ADDTl'ION
❑ REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�� �
,TE�A AJZIP�$
� � Jt./
BASEMINT REMODELING SL MTI'•
1. Existing Floor Plan
2. Propos� floor plan
3. List of structuta( members to be used
SIDING FOR NEW CONSTRUCTIOid INCLUDING DECKS,
0 Vinyl �Sofiit t1DDITIONS &c PORCHES SUBMIT•
����� ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia �d P�Pos� P%1�
2. Two sets of constructi�f plans
WINDOWS 3. Energy Calcuiations
IN EXISTING OPENINGS '�Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALLJE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF '�,Lg Q,�, +f (�p m t �- l b roc�m MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES 8t L C a� ��.,,..�- � i- LS
TYPE OF WINDOW TO BE INSTALLED ER OF WINDOWS
ALL FEES ARE BASED ON VALUATI , INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDLTLE)
TOTAL JOB VALUATION $_.�_� O R OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Conh�ol
Park Fee
Sewer Main Charge
$ 4 L I."LS See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 rimes 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}
S ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ F� Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � Make checks oavable to: Citv of Fridlev Attnc
THIS I5 AN APPLICATION FOR A PERMIT-NOT VALID UNTII. 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; t1�at I understand this is not a
permit but only an application for a permit d 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 all wo ich r uires review and approval of pl s.
SIGNATURE OF APPLICANT ��� Q pgINT NAME Yl � n,�o� s�f9(�fSc,� DATE 7i ����id 11
APPROVAL INSPECTOR SI('rNAT[JRF.