P - 37231Building BUILDING Permit No. �t'l , v d 5�
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604
763-502-4977 FAX CITY OF FRIDLEY Date Rec'd: �`t ( �
EFFECTIVE 1-1-2011
DATE 0 I j� YOUR E-MAIL, A^D/D�Ij,�SS �
SITE ADDRESS (��� �(//1�%(it�i�7'}v� �(' l �' G
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
❑ OWNER �CONTRACTOR
NAME: 1 ' t-G �, �`�
ADDRESS: � � `�, D �" ��
PHONE: �63' '�� � �^ � Z Z b
NAME: �i r v� ��7� r
STATE LICEN$E #t �` d C� �
ADDRESS: W �G
PHONE ��j � �" C,� � " � (9 �
iF SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH � ROOF
❑ DECK ❑ SIDTNG
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADD[TlON
❑ MAINTENANCE/REPAIR ❑ REMODEL:
'I DESCRIBE WORK BEING DONE: �/L
I SIZE OF [MPROVEMENT LENGTH TI
ROOFING D HOUSE ONLY
I NUMBER OF SQUARE3 ��_ ❑ HOUSE & GARAGE
' GARAGES
I AROPOSED SIZE:
� pROPOSED HE(GHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
1N EXISTING OPEN[NGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
ITY _�(o (,� ��
� � r
EAD CERT NUMBEA
CITY �'
FAX
SIZE
STORIES
❑ W[NDOWS
❑ DRAIN TILE
❑ OTHER
ATE .rn,NZ[P
�3�'s =l
TATE M/✓ZIP�
FT
BASEMENT REMODELTNG SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDING 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 WTNDOW.
- _ __
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USIN�THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ Z C.Q 3 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
$ � �► �S
$
$ -
$
$ � • o�—
$
$
$
$
$ .
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 ( )
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 wiil be in
conformance with the ordinances and codes of the City of Fridley nd 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 rt without a permit on site; that the wor will be in ac ordance with the
approved plan in the case of which ui revi w pro�al of plan�� ft j
SIGNATURE OF APPLICANT NAME �(/� �✓ DATE ��� �/
APPROVAL INSPECTOR SIGNAT iC /�i
ZS'S`�S