P - 35764Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
F,FFECTIVE 1-1-2011
Permit No. �� � 1
Received By:
BATE_ ! j� VU I 1 1 YOUR E-MAIL ADDRESS f�k' 15 Qh (� r ��--�ra �!1 �! �S C� C almL tx 5'�'• Y� E
siTE aDDxESS 5 p(� q C l�C�rv `� S� e 2�-�- N� C
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBNIIT A COPY OF
YOUR STATE LICENSE
AND CERTIF'ICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
❑ OWNER
NAME: �dY�t(� 1�K�1 V`""�1
ADDRESS: SU�a CIE'GI�tL°�n
PHONE: �D��O -3a��3J��O
N
a
STATE LICENSE #�) �r ( O�D o�O LEAD CER NUMBE
anDxESS: 134 I°� � til � c�_�'� �1 �� ct�_
PHONE �nS� —� o� ��9 I ZC FAX i/� �J /—
c
�`6iiVGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STOF
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK �i'siDING ❑ OTHER
❑ S WIMMING POOL
❑ NEW HOME CONSTRUCTTON O ADDTITON
,Q'MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
�e. �n cs�. t
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHELi GARAGE
❑ DETACHED GARAGE
STA'I'F�/V ZIP�
�-�oiSCo��- 1
, STAT�ZIP
� y9 �.1
�, k1oU Sa, �
C' 4'� _ __ �i
BASEMENT REMODELING SUBMIT:
1. E�risting Floor Plan
2. Pmposed floor plan
3. List of structural membe=s to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDTl'IONS. & PORCHES SUBMIT:
�a�u���� ��^ � ❑ T� L Site PlanlSurvey showing the existing shuctures
�.r ❑ Fascia and proposed project.
2. Two sets of canstruction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTVRE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLEI} NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERiALS:
TOTAL JOB VALUATION � �(")�Q Q Q 19Q,7 U.B.0 FEE SC OCCUPANCY TYPE
�---
Permit F�
Plan Review
Fire Surcharge
S�u�charge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � iS I�r�5 See Back Page for Fce Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ ��j $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 uavable to: Citv of Fridlev Att�ch
THIS IS AN APPLICATION FOR A PERMTI'-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
co�ormance with the ordinances and codes of the City of Fridley a� with ti�e Minnesota Constnxction Codes; that I understand ttus is not a
permit but only an application for a permit and work is nat to start witt�ut a permit on site; thai the work will be in accordance with the
approved plan in the case o work which requires iew approval of plans. ���,�` g l
SIGNATURE OF APPLICt��'� ,�_� INT NAMETP�I S"r C N M, TN� DATE O+3 I((
APPROVAL INSPECTOR �IGD�