2011-02088Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /U /
SITE ADDR SS��
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTtV£ 1-I-2011
�OC U�R�-MA� ..�DDRESS
.kvr�l `' TC"i /` 1 �v
O OWNER ,CyICONTRACTOR
NAME:�_ So��'oJ'�, v�
ADDRESS O � or �
PHONE:
NAME:_�O �r
STATE LICENSE #
ADDRESS: �°��l �� Vl � VL( Si'�"`ti �
PHONE 7�°5 /I �I I�
� SINGLE FAMtLY/NEW CONSTRUCTiON
❑ TWO FAMILYMEW CONSTRUCTION
[yy�9
Permit No.: r i� ;,� �
Received By:'
D�.�'�'��°� � ����
ATE�ZIP��
LEAD CERT NUMBER
CITY i STAT��IZIP�
FAX
SIZE
STORTES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT F[NISH ,1d ROOF ❑ DRA(N TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMMG POOL
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENIIJG CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
HEIGHT
F7'
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION [NCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site PlanlSurvey showing the existing swctures
and proposed project.
2. Two sets of conswction 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 MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ -��^ D 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
$ 113 � ZS
$
$ %�—
$
$ 50
$
$
$
$
Q
$
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 pa_yable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L 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 o 1 ork w' h requires review and approval ofp�lans. �J �}- /y��
SIGNATURE OF APPLICANT _ PRINT NAMEC/�%.c� Tb,r.- �`�� WeikT�DATE �Ld�/� �
APPROVAL INSPECTOR SIGNATURE T