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Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date �s�c1� ��%��
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE � ��I�` � I YOUR E-MAIL ADDRESS �%�{Jr1i��iL �%i0��c�V(�i(,�L . C0�
SITE ADDRESS �a 5"'S� � . F�Y��I(— � .
THIS APPLICANT IS: ❑ OWNER C�CONTRACTOR
PROPERTY OWNER/ NAME: l.. C..��� Q�'�'
TENANT ADDRESS: i�0� �J J�• � i J�� 1� 1� • CITY � W STATEm/v ZIP 3 a
PHONE: � �'' �'��} (p 7 �p
CONTRACTOR NqME; 0
SUBMIT A COPY OF STATE LICENSE #�O a�" � • LEAD CERT NUMBER JI a�� � I
YOUR STATE LICENSE � m��
AND CERTIFICATE OF ADDRESS:�d�l �/1'? �"� � LS CITY �' TATE/� wVZIP�
INSURANCE NE � �� � �� � FAX � ' � "�(, �
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ,p GARAGE/5HED ❑ WINDOWS
❑ BASEMENT FINISH ��/ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: NEW HOME CONSTRUCTION ❑ ADDITION
1NTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: V U-
SIZE OF.IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING HOUSE ONLY BASEMENT REMODELING SUBMIT:
* NUMBER OF SQUARES 1� HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPO5ED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
� Other O Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALLTE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL N'r;r:� AKL 13A5r:ll UN VALUA"1'lUN,1NCLUll1NG "THE COST UF LABOR AND MATERIALS:
� �S�IC'�HE 199'7 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
"�I UVLJ OCCUPANCY TYPE
$ 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 Deternuned by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ . 1 Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pernut 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 foi 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 • c ic req � iew a approval of pl �
SIGNATURE OF APPLICANT PRINT NAME�Vr �� e� �rU �� DATE lal � 3! � �
APPROVAL INSPECTOR SIGNATURE
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