P - 36665Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:� �i
Received By;� �
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DATE YOUR E-MAIL ADDRESS o1l1QLfJCl� �,�L�N�%?/%.C.-�/��
S[TE ADDRESS d7/ !0 ��i/La�S�//���j �j'- /1/ L�
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
NAME: /' .
ADDRESS: /p �Q�'1QS�/� U ��
PHONE: %!03 —�0����f�—
STATE LICENSE #
/\7�77�.Y.Y
C[TY
LEAD CERT NUMBER
PROPERTY TYPE ❑ S[NGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH /�ROOF ❑ DRAIN T[LE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ N W HOME CONSTRUCTION ❑ ADDITION
�AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �,
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Viny1
❑ Aluminum
❑ Other
LENGTH WIDTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
STAT�ZIP�
--pp3- -
�STAT 2
� /.P..7�
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUGTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
O Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE S[ZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
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)
TOTAL JOB VALUATION $/ D�iI�, t� /' 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
$ �$� _ZS See Back Page for Fee Schedule
$ � 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $S.OQ
$ "j� $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 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 ridley .and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a s not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all wo review and approval of �
SIGNATURE OF APPLICANT PRINT NAME /� ,�C,LLy�/Q./� DATE
APPROVAL INSPECTOR SIG TU