P - 60286Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � �/� ��
SITE ADDRESS ��
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2011
❑ OWNER
PROPERTY OWNER/ NAME:
TENANT ADD�s
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
YOUR E-MAIL ADDRESS
RACTOR
� � � C� � %-�..0
_ f .C-�6 — ��5
Permit No.
I•- -� : �1:►'
� .��,. . ,� �� r .� � . �
r
A'�.
NAME: �C10. KcsO - `�'^n ��
STATE LICENSE # IO �71 ! LEAD CERT NUMBER N�- a5o�y
ADDR6SS: 4�00 �,�(G,C"jjOP C3�\Jc� CITY'�w�Ocxis �.+AR. STA
PHONE q5�' � �5 `�7?�4 FAX C{6� - �t ."11 - 4q9�
:0'SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH -�'ROOF ❑ DRA[N TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDIT[ON
C�-i'vTAiNTF.NANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:�
KJ
SIZE OF [MPROVEMENT
ROOFING �
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
� Vinyl
❑ Aluminum
O Other
O HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
� DETACHED GARAGE
HEIGHT
FT
ZIP5sVi4
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION [NCLUDING DECKS,
�offit ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1• Site Plan/Survey showing the existing structures
and proposed project.
.,�"�'ascia Z, Two sets of construction plans
3 E � Calculations
W[NDOWS neigy
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPEMNGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPEN WG CHANGES &
TYPE OF WINDOW 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)
TOTAL JOB VALUATION $�.�- ��I.s� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �'l � l �cl 5
$
$
$ �
$ �
$
$
$
$
$ � �
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$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: City of Fridley
Attach Stipulations
THIS IS AN APPLICAT[ON 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 all ork which req r�re�%ew and approval of pl ns. � �/
SIGNATURE OF APPLICANT a( �Yt.[,.lu PRINT NAME�q n� � I+ Gk DATE �1 ��� 1�
APPROVAL INSPECTOR SIGN� RE
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK