P - 47736Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � '�3 `��
BUILDING
RESIDENTIAL APPLICATION
SITE ADDRESS � � � �J r��-f��
THIS APPLICANT IS: ❑ OWNER
ricur�K'1'Y UWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING DOP
SIZE OF IMPRnVF.MFt�T
CITY OF FRIDLEY
EFFECTIVE 1-l-2011
YOUR E-MAIL ADDRESS
NaME: �I �!1 N f�" O✓H /�j —
ADDRESS: 3 � �� CITY
PHONE:_ ' (t?`�j / '� p / 7 g�`
NaME:_� I I h'1 !��-.Q/�- '
STATELICENSE# �0�
PHONE
o t-r
' V/��
.- 5�97'7 .
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ��GE/SHED
❑ BASEMENT FINISH OOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ A ION
❑ MAINTENANCE/REPA]R c� �n�T-.
ROOFING
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
[N EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
� E ONLY
HOUSE & GARAGE
❑ A CHED GARAGE
ETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER nF wtt.rnrnue
r�
Permit No.: °� � l�
Received By:
Dat���:J�� .������
TA
L�;AD C T NUMBER
� CIT�� (��c. STATF�/� ZIP S ,S� �
FAX
SIZE
❑ DRAIN TILE
❑ OTHER
WIDTH HEIGHT
FT
BASEMENT REMODELING 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 WINDOW.
tiLL r��,� AKr; BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $-1� �USING THE 1997 U.B.0 FEE SCHEDULE)
r' o � `�� OCCUPANCY
Permit Fee $ _ _ TYPE
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
. �.
$
$
$
$ �d
$
$
$
$
$
$ .
�ee tsack t'age 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+( ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks a able to: Cit of Fridle Attach Sti ulations
THIS [S 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 and wo k is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all o k hi equi review and approval of pl —I
SIGNATURE OF APPLICANT PRINT NAME��c;�J(I C�ji� /F/Q/�j� DATE CP" �3'���
APPROVAL INSPECTOR SIGNATU