P - 44535Building BUILDING Permit No.: ��
Inspections RESIDENTIAL APPLICATION Received By: /VI.
763-572-3604 CITY OF FRIDLEY nat��a�PR ������
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE t/ ��S� � YOUR E-MAIL ADDFtESS S�GHt� C✓��� /�^Cn c�f _ C"o�-r1
SITE ADDRESS �
THIS APPLICANT IS:
I PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPI�' OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
❑ OWNER
CITY
ATE N�✓ZIP cS3'jL"�,�Z
Nwn��;: � rw r;mc., LG�• 3—�.�.11,�.. �7✓S.
STATE LICENSE # ZQ �D 3�S_ I� LEAD CERT NUMBER
ADDRESS: �LiSLI3 i,��"*-.1�- S�i CITY /'1�r. LcICt STATEM�I/ZIP SS'3!�
PHONE ?G3— YY3-169y F,�c %le?�- 7Fi0 - t�%d �
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ ARAGE/SHED
❑ BASEMENT FINISH OOF
❑ DECK SIDING
❑ SWIMM[NG POOL
❑ NEW HOME CONSTRUCTION ❑ ADD[TION
❑ MAINTENANCE/REPAIR !�:REMODEL
DESCRIBE WORK BEING DONE:
SIZE OF (MPROVEMENT
ROOFING � �
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
IS DIN�
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
M EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WMDOW TO BE INSTALLED
L] HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
HEIGNT
FT
BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan
2. Proposed floor plan
3. List of suuctural members to be used
FOR NEW CONSTRUCT[ON fNCLUDING DECKS,
f#DDITIONS. & PORCHES SUBMIT:
1, Site Plan/Survey showing the existing structures
and proposed project:
2. Two seu of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STfCKER 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 l• ZS See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .00] times the total job valuation
$ ° �- .00QS 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 Pian 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 1 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 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 al �o �'� ' h.re es review and approval of plans./ r�> �� /� (�
SIGNATURE OF APPLICANT PRINT NAME_�'1-r ,,,.t_ l:]�/✓'�' DATE /-oZ•S�� //
APPROVAL INSPECTOR SIG ATURE .