P - 47350Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-t-2011
Permit No.: °t6��� � 3
Received By:
il�1�e��e�'t�! �
, DATE (�j ' I�U ��� YOUR E-MAIL ADDRESS �ct�t 1� K��/�7Z.TS�iY C� • G c�M
SITE ADDRESS �OC� / �'IC�(�!�"'G i`'i'�/�
THIS APPLICANT IS: ❑ OWNER �60NTRACTOR
PROPERTY OWNER/ N,aME: '1,.�. I S / ZT -/
TENANT ,qDDRESS: S�Cn ( H UG7/�� S/k�l�' CITY (t-� pC.C.� STATE iNN Z[P 'J`�S y L/
PHONE: �(c�3 " �S �Z, ' ^ �jZ c,Zi �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING D
SIZE OF IMPROVEMENT
NA1vtE: G7/E27�r,�.7�1 Lon•� F�r H K
STATE LICENSE # l�I (o LEAD CERT NUMBER
ADDRESS: S3 QS �� ��v C.� /�I CITYL7oL��/ (�/� C,C.t.-s7,�TATE/N/�%LIP $��/2 ,�-
PHONE
' lSao
�3INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FIN]SH �OOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�Il9AINTENANCE/REPAIR ❑ REMODELING
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ 9luminum
�'Other ____
WINDOWS
IN EXISTING OPENTNGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
^�J-k�OUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�Soffit
�,Trim
�'ascia
LOCATION OF WiNDOWS
NUMBER OF WINDOWS
") T-► �
WIDTH HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Exis[ing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. 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 $ I`I . d� • 4d 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
$ �'� ���
$
$
$
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Buildirig 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 navable to: Citv of Fridlev
Attach Stipulations
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 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 a�ll �' rk which requires review and approva] of pla�.n ,_
SIGNATURE OF APPLICANT l//�----'�'�" PRINT NAME�}.� 1GLdMY1C��- DATE� / I
APPROVAL INSPECTOR SIGN URE