P - 44547Building
Inspections
763-572-3604
763-502-4977 FAX
DATE� � � 7 � D / I
SITE ADDRESS "t0 f �oL
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTTFICATE OF
1NSURANCE
PROPERTY TYPE
BUILDING � Perrnitrto.:���,� ��'' ' - `�°��
RESIDENTIAL APPLICATION Received By:i���= �
CITY OF FRIDLEY va{��'c� L Q l 11
EFFECTIVE 1-1-2011
YOURE-MA[LADDRESS OCS � (�w�c=�-�-�FtLe,� !V'L T
� �� � sr N � '"
❑ OWNER �ONTRACTOR
NAME: J'rN�iJ/Sft' C�!%UN
ADDRESS!��O �j/LD Ar�
PHONE��j� — . �� + �']I �i
NAMEC%QIf9hY C:O/�� �j�ph
STATE LICENSE # ��1430ds�`{j .
ADDRESS:��y �J T�Gtp�/Y/¢ L�
PHONE 7a � �-7�Q �% — y�D �
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE I �
CITY
AT�Z[P S.S3d3
EXP DATE �% 3 /3 / //�
T� CIT1�`j�'�/{'�K STA
FAX��� --3a �--��o y
SIZE
STORIES
❑ GARAG
�'ROOF
� SIDING
� SWIMM
TYPE OF WORK: �❑ NEW HOME CONSTRUC770N
I�gMAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES � � /j�
GARAGES (�V' �
PROPOSED SIZE: �
PROPOSED HEIGHT:
SIDING
.B'Vinyl
❑ Other
WINDOWS ��
IN EXISTING OPENINGS ydYes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ DRAIN TILE
❑ OTHER
NG POOL
❑ ADDITION
� ING
:�t�'' � Qer � i�t
,
WIDTH HEIGHT
❑�-IOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�'Soffit
BTrim
�Fascia
LOCATION OF WINDOWS
RLL-
BASEMENT REMODELING SUBMIT
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTtON INCLUDING 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 WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�(USING THE 1997 U.B C F E SCHEDULE)
TOTAL JOB VALUATION $ �v.--O�6p�°--�Ig,��- OCCUPANCY TYPE
Permit Fee
P(an Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totat Due
$ �,C�-.1J iC��
$
$ )
$
$
$
$
$
$
$
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$24=$
$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 LJNTIL 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 p it and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in th a or '� u' es review and approval of�plans.
SIGNANRE OF APPLI NT NAMEj�N ��1,i s�OoJ DATE �. —S —� a��
APPROVAL INSPECTOR IGNANRE . ,