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Bu� ing BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By: '
763-572-3604 CITY OF FRIDLEY Date Rec'd: 1�
763-502-4977 FAX EFFECTIVE 1-I-2011
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DATE Q G �O t YOUR E-MAIL ADDk2ESS M�� �J 2.S 't q°� � K 9 � j�
SITE ADDRESS l� 9�o S !-r � tlG %G � R C i�� /l% �
THIS APPLICANT IS: ❑ OWNER [�ONTRACTOR
PROPERTY OWNER/ NAME:
TENANT pDDRESS
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICEN5E
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
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STATE LICENSE #�I �S �% LEAD CERT NUMBER �J ArT� J%.S
ADDRESS: 3 73 9 /�i : A1 Il� � Q- �1 a- %b uG CITY M PL'S STA
PHONE lo � i � % a �" .5�.� .3 � FAX G � i — % � l � � � O •
�3'SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAG
❑ BASEMENT FINISH ❑ ROOF
� DECK ❑ SIDING
❑ SWIMM
TYPE OF WORK: (❑ NEW HOME CONSTRUCTION � ADDITION
� MAINTENANCE/REPAIR ❑ REMODELING
❑ DRAIN TILE
O OTHER
DESCRIBE WORK BEING DONE: I 7 �' N S�- �� W[�/J O w' S ,- d O�S � S Ti
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
O Vinyl
O Aluminum
❑ Other
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION [NCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES �UBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS ���� 3. Energy Calculations
M EXISTING OPENINGS.iCIYes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENIIVG CHANGES & a L se. P ae.t fl o o uN ,/
TYPE OF WINDOW TO BE MSTALLED Y� � NUMBER OF WINDOWS � T
ALL FEES ARE BASED�N VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
� 773 � (USING �1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
$ ��( • �
$
$
$ .
$ s, .
$
$
$
$
$
$
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 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 w k is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of al ��vork whic req ' eview and approval of pl s ,I
SIGNATURE OF APPL[CANT PRINT NAME �R� � � f�'QT/�� DATE �� 6��A /'
APPROVAL INSPECTOR SIGNATURE