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g BUILDING Permit r�o.�
Inspections 12ESIDENTIAL APPLICATION Received By•
763-572-3604 CITY OF FRIDLEY Date��'�1:4PR . ����
763-5�2-4977 FAX EFFECTIVE 1-1-2011
DATE � / �/ - � � YOUR E-MAIL ADDRESS
SITE ADDRESS �i fU f7'L14 L� ,� Y`= iLf.�
THIS APPLICANT [5: $�'OWNER ❑CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME: I�o �'-� CtoJ'�=�z -�
ADDRESS: G!v lY�tya S�� !�� CITY Fi"���/�� STATE,/�� ZIPS3`t`��
PHONE: %{'o � ' � � � - ,Y-� �'/,� -�
STATE LICENSE # LEAD CERT NUMBER
ADDRESS': CITY STATE ZIP
PHONE p,�
❑ SINGLE FAMILY/NEW CONSTRUCT[ON SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
IJ ADDITION ❑ GARAG
❑ BASEMENT FINISH ❑ ROOF
� DECK ❑ SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
❑ DRAIN TILE
�OTHER
DESCRIBE WORK BEING DONE: /P��la �-� �. $ ec7`,�y��° � CDf7L+�°GT�e G�ur.6
SIZE OF IMPROVEMENT LENGTH WmTU uF��uT
RQOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
O HOUSE ONLY
� HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINbOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
�
BASEMENT REMODELING SUBIvIIT•
1. Existing 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 swctures
and proposed project.
2. Two sets of consVuction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
fOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Chazge
Total Due
$
$
$
$
$
$
$ 2?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+�= ftx$2g=$�,�
$450 Cons rvation 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 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 work �ch re ires review and approval of pl s.
SIGNATURE OF APPLICANT �d���� PRINT N.4ME �aG z G�j"c .`r e y DATE ���� ��
APPROVAL INSPECTOR SIGNATURE �