P - 39371Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
Permit No.:`�ti �
Recei��,y
�
Date Rec�d�
DATE � —� �� YOURE-MAILADDRESS CT [���c.K�J,�q�.�,..� /1-�-��V , (;bi'✓1
SITE ADDRESS E �L � ��`�,jp,p,�'tw.� �=I
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: �hte. t3. RAd.I��
TENANT qDDRESS: i LI `� ��� 1 bR v�.i r� CtTY �R aGI �-� STATE ZIP
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
NAME:�fl(.w
STATE LTCENSE #
LEAD CERT NUMBER
ADDRESS: ��I So ��Ja-TSo� S'T CTTY £1K R�.��� STATE►'� ZIP S�j 33a
PHONE _ ��03° a•�J�- �o Llc'I �'� FAX % (� �i— � �l - � g�5�-
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE_
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAM TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION � ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING
SIZE OF (MPROVEMENT
ROOFII�'G � �
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Oiher
❑ HOUSE ONLY
❑ HOUSE & GARAGG
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
FT
BASEMENT REMODELTNG SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of struc?ural members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
❑Soffit ADD]TIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
� Fascia and proposed project.
2. Two sets of conswction 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 MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WtNDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Pertnit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � �-ct5
$
$ ' �
$
$
$
$
$
$
$
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 Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks payable 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 acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of t e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a erm' or ot to start without a permit on � that the work will be in accordance with the
approved plan in the case of all r � view and approval of pla . y�
SIGNATURE OF APPLICANT PRINT NAME �i�iy DATE �� �✓ '��