P - 35773Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � I /�
SITE ADDRES _�
TH[S APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-201I
Permit No-�
Received By:
Date Rec'd: 1
YOUR E-MAIL ADDRESS __ �/YlE� r� �il/ ���JO¢f2 ic/�L LrX %��/'1>�'Zc9 rLs�,_�
�' 1� r�- i°�C'u�a � .�i•4 .
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE .
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
❑ OWNER j�CONTRACTOR
NAME: �}�_C.�'i.,, b:l.t�--
ADDRESS: � 7 S � / K�'z CITY
PHONE: CFl e�. jPg " C�D,j S
_, � � ,
NAME: s�/i''v � 5.-,
STATE LICENSE # `� ? �' � � D
ADDRESS: � D �S�.Li • R25/?/E-
ATE�ZIP 3.�� YJ� �
CERT NUMBER
CTTY �%�i STATE�ZIP S.S/,3
PHONE ��/— .�?%�/— �,S_j ��— FAX (�j�/- 77�/'
❑ SINGLE FAMILY/I�tEW CONSTRUCTION S[ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION � GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TiLE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
i:�t�7.lsrcsn-•a��t//.�✓� � '�` !74//1J f .S c�j��� ASG/o9
IS DING
❑ Vinyl
❑ Aluminum E •
❑ Other �
❑ HOl1SE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�Soffit
❑ Trim
JB,Fascia
WINDOWS
IN EXISTING OPENINGS I�Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
HEIGHT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor pian
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDING DECKS,
ADDITIONS, & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of conswction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE ST[CKER 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)
TOTAL JOB VALUATION $_ a�/.�d4 � 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
���
�w
.� ��r
• •
111�ii�i
See Back Page for Fee Schedule
65% of Bui(ding Permit Fee
.00] 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 pavable to: Citv of Fridlev Attach
lations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
i hereby apply for a building permit and 7 acknowledge that the information above is complete and accurate; that the work wilt 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 pe it and rk is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of/� 1}�'o e' review and approval of pl�n�/� ,�� ���fL�
SIGNATURE OF APPLICANT G!/ PRRJT NAME l,�J �l/•��x '�llATE �'�/�/�
APPROVAL INSPECTOR SIGNATURE .