P - 48043Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE � ' / � �� YOUR E-MAIL ADDRESS
SITE ADDRESS �p �,� S �lL�'Cjll.� �'77`' /f/ �'
THIS APPLICANT [S: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
Permit No.:���,�� � (,�.����'
Received By: ' ° "�
D���°��N p 7 201�
NAME: U.7dN G.��'A/-�L
ADDRESS: �O�ia2� �'L�iyly S`i ��' CfTY �lF��'y STATE�ZIP
PHONE: �v I,� — S°I °'( ��(o a 3
STATE LTCENSE # � {') (� � (p Y � � LEAD CERT NLIMBER
ADDRESS: � l a D 1�-(.L.��/1Q 1f CITY -TfVVb?2 �UL�' STATE•n.y�/GIP S$a�'j
PHONE FqX ���''�S
�INGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
❑ NEW HOME CONSTRUCTION
� MAINTENANCE/REPAIR
❑ GARAGE/SHED ❑ WINDOWS
:� ROOF ❑ DRAIN TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
DESCRIBE WORK BETNG DONE: `�-�L�p�' ��L�� F' S� � S�()
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT
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
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION 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 MATERIALS:
USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ � S,� OCCUPANCY TYPE
�� Permit Fee
�, P(an Review
� Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ill.��
$
$ �
$ Cti � —
$
$
$
$
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+68= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks aavable to: Citv of Fridlev
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 wil] be in accordance with the
approved plan in the case of all w q' s review and approval of p s, --�" „�
SIGNATURE OF APPLICANT PRINT NAME �%Z� /Q��vj�py�% DATE � P�"—��
APPROVAL INSPECTOR SIGNA URE