P - 35792Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
Permit No.:% `�`J � Li (�'
�/�r
Received By:� V iil�
�#�e�ii�L � � ����
DATE � � °� // YOUR E-MAIL ADDRESS G'�'��-�c-�C.'-t?-Z?t-a�� c� ���.�� . � �
SITE ADII SS r7So � /,49�/F 5��f�s'�iv. '• F�2i' i�LE % iyj,�/ 5'S �/3.�
THIS APPLICANT IS: I�°OWNER �CONTRACTOR �
PROPERTY OWNER/ N,at�E: C.���'s Koc,��5,���
TENANT p,DDRESS: %SO/ �/� YG�� ST� ..v • E- �
CITY Fipi i) L� S� STATE/Z/NZIP ✓�S"y3 o'�-i
PHONE: `%�o �% i' fo � � a�-
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
STATE LICENSE #
ADDRESS:
PHONE
I$ SINGLE FAMILYMEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH
❑ DECK
G�ROOF
❑ SIDING
❑ SWIMMING POOL
LEAD CERT NLIMBER
CITY
FAX
SIZE
STOR[ES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
❑ NEW HOME CONSTRUCTION ❑ ADDITION
C�jMAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: �Q E.1�L/4 G'i�.J G/�d-D F
ROOFMG '
NUMBER OF SQUARES � y
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDIN
❑ Vinyl
O Aluminum
❑ Other
WINDOWS
IN E3fISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS•DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WMDOW TO BE INSTALLED
❑ HOUSE ONLY
i�I-IOUSE & GARAGE
/I� ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
O Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
WiDTH
ATE ZIP,
FT
BASEMENT REMODELING SUBMIT:
1. Exisiing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTtON INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project:
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totat Due
$ q�[��-
$
$ `
$
$
$
$
$
$
$
TERIALS:
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$SAO (State Licensed Residentia! Contractors)
$2230 per SAC Unit (Ptans 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 the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application a permit and w is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case 1 wl�ic ' es review nd approval of plans.
SIGNATURE OF APPLIC � � PR1NT NAME L� i4CRi 5��Ci`,it/ S.�i� DATE ��Z8'. oZpi/
APPROVAL INSPECTOR GNAT E 77�