P - 42845Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:
Received By:
Date Rec'd:
DATE I I YOUR E-MAIL ADDRESS �)w sr� k�tct� (�c�, �-fi
SITE ADDRESS %'�S� 'C�� 11!('S't�o'�'1 D� � N�
THIS APPLICANT IS: ❑ OWNER -�4,lNTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
NAME: `�Q�'Gt �JJait�!!'f"r
ADDRESS: ���D IL�P.at IL� S�a�t DJ' N� CITY
PHONE:
N
TE�`� Z[P SS�f �"
STATE LICENSE #_. �l1SI� SY�,� LEAD CERT NUMBER N� � 5��30 � �
ADDRESS:_10(,�1�2 4w•��1�G2��0 (7� i'✓ CITY�� �""'� STATE/"�'�ZIP S�'3�9
PH4NE -- �e �J' ". �'iG%T7 _�i 1Z�''f FAX � � �Q?7''a'19��
PROPERTY TYPE J�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ ADDITION O�IRAGE/SHED
❑ BASEMENT FINISH ,�ROOF
� DECK ❑ SIDING
❑ SWIMIvfING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �EMODEL
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES ��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
i WINDOWS
i IN EXISTING OPENINGS ❑Yes ONo
; OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
� TYPE OF WINDOW TO BE INSTALLED
k
�❑ USE ONLY
USE & GARAGE
❑ TTACHED GARAGE
f�?'�ETACHED GARAGE
❑Soffit
O Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
SIZE
STORIE�
❑ W[NDOWS
❑ DRAM TILE
❑ OTHER
0
BASEMENT REMODELING SUBMIT:
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 Pian/Survey showing the existing sVUCtures
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 $ . 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
$ I� �. ZJ� See Back Page for Fee Schedule
$ � 65% of Building Permit Fee
$ .001 times the total job valuation
$ `�� .0005 x Permit Valuation Minimum $5.00
$ Z, O(] $5.40 (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 Fridiey 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 a o is not to start without a permit on site; that the work will be in acc dance with the
approved plan in the case of al rl ic qu es eview and approval of pl s.
SIGNATURE OF APPLICANT PRiNT NAME �� PQrt-�'1.�OL DATE l� � � I�
APPROVAL [NSPECTOR SIGNATU /�