P - 43788Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
DATE I d" � y�� !� YOUR E-MAIL ADDRESS
SITE ADDRESS 5 LI S �(��+ 7�'� �{ YvC�
THIS APPLICANT IS: .�CIWNER ❑CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE ClF WORK:
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
NAME: .�C�'�' L�w✓�<^�C C,
ADDRESS: ' ��'�- � S � �CTTY
PHONE: %�,3 " %�% Z— �
NAME:
STATE [.ICENSE #
AADRESS:
�17d5'/IQEW CONSTRUCTION
YMEW CONSTRUCTION
LEAD CERT
FAX
Cl7Y
❑ BASEMENT FINISN %�OOF ❑ DRAIN TILE
❑ DECK SIDiNG � OTHER
O IMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
b7�taIAINTENANCE/REPAIR ❑ REMODELING
WINDOWS
IN EXISTING OPENINGS �s �No
OR FOR NEW OPENINGS-D SCRIBE SIZE OF
OPENING CHANGES & �j�
TWE OF WMDOW TO BE INSTALLED O�i1°
O HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
__ NUMBER OF WINDOWS_ __ `
HETGHT
Permit No.:
�- -. :
� �
� � ��� ���- � i
ATE �r�l� ZIES.� Z
ATE ZIP
F7'
BASEMENT REMODELING SUBMIT
1. Existing Floor Pian
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site PlanlSurvey showing the existing structures
and proposed project.
2. Two seu of construcYion plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE ST[CKER ON WINDOW. i�
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB �ALUATION � , S S� � 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
$ � Z�L,�j 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 ( )
$ � ;,'-j 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 applicatian f 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 all w rk � uires reviev+l. and approval of plans� �/ �� /�w//
SIGNATURE OF APPLIGANT PRINT NAME co /�.�✓YyiC L', DATE
APPROVAL INSPECTOR SIGNATU __ _ __ _