P - 41788� f� i�;
Building BUILDING Permit No.�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'd: �
. 763-502-4977 FAX EFFECTIVE 1-]-2011
DATE c� ' f ' u
S]TE ADDRESS ! �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
YOUR E-MAIL ADDRESS
❑ OWNER CON'.
NAME: �
ADDRESS: � �
n,.�,,.,.-. �n lJ° .. r-," `7,P -
NAME:_, ( �A��
STATE LICENSE #
PHONE - ?� y - a� �{�
INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
O BASEMENT FINISH
❑ DECK
CJ NEW HOME CONSTRUCTION
�J.MAINTENANCE/REPAIR
❑ ROOF
O SIDING
❑ SWIMM
CITY
SIZE
� ADDITION
❑ REMODELING
- _A.. �
CERT
0
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ATE I%17 ► ZIP
nr��x v� i v c.c i �
�/ l41 d /�;�eCU STAT '�1 _ZIP OI
� DRAIN TILE
❑ OTHER
�ic.cvrirvtrtcvvnrvinivt Lt1VVtri W1ll�1�H HEIGHT S FT
� ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SU3MIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE �, Existing Floor Plan
GARAGES � ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: O DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl �Soffit ADDITIONS_ & PORCHES SUBMIT:
O Aluminum O Trim 1. Site Plan/Survey showing the existing structures
O Other O Fascia and proposed project.
2, Two sets of construction plans
WII�iDOWS / � (�t'��. �,ClZi1'i'►'t 3. Energy Calculations
IN E9CfS'TING QYEIVIi�iE?S es ❑No OCATION OF WIN} WS �y.� FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-D SCRIBE SIZE OF �' /t�Q�111 '1 ��,Ur''�'l YY� MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & �,, �f,,/-
TYPE OF WINDOW TO BE INSTALLED �X�.h NUMBER OF WINDOWS �T
ALL FEES ARE BASED ON VALUAT ON, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $$. o?�° See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ . .001 times the total job valuation
� Surcharge $ j,,j �.0005 x Permit Valuation Minimum $5.00
License Surcharge $ �', �� $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
�'�Curb Cut Escrow $ f� + 6 ft= ft x$24 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ . 7,� _ Make checks payable to: City of Fridley Attach Stinnlations
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 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 a 1 work w �,ich re �res review and approval of plan .
SIGNATURE OF APPLICANT �/`X/J C�II�J�� PRINT NAME Y/.� O/YI � DATE �' 7' l�
APPROVAL INSPECTOR SIGNA7'URE