P - 48575�►�'ding BUILDING
Insp�ctions RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502�49%7 FAX EFFECTIVE I-I-2012
DATE �3 -� b���" YOUR E- L ADDRESS
si�,a�DxESS �c�e`� ^ /'`-1� r.�L � �.�� jZ,z� t-� `-� , fi
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE
❑ OWNER
i'-��.L i%�� C�C�f-c IZ��T c.�
ADDRESS: •5 ��J' I` 3/2b Sv fi` /�� CITY
PHONE:_ � �.� '--�00 �—�cYD �''
Permit No.
Received By:�
Date Rec'd;�; �
3 Z--
� �SS a Z
NAME: ��C-td- C B�tL s��-t-� �`�i [` ti
STATE LICENSE # LEAD CERT NUMBER EXP:
ADDRESS: 16.5�L.5� r4� t� �-�� S✓ CITY��'i.�} ( e�E STATE!1 IP 5,�
�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCI'ION
❑ BASEMENT FINISH �ROOF
❑ DECK O SIDING
❑ NEW HOME CONSTRUCTION ❑ ADDITTON
�QAINTENANCE/REPAIR „ ❑ REMODEL:
DESCRIBE WORK BEING DONE: l��--/
SIZE OF IMPROVEMENT
FAX
SIZE
❑ WINDpWS
❑ DRAIN TILE
❑ OTHER
�
FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �iZ- �'HOUSE & GARAGE BASEMENE 'RE gOD�i p�G SUBMIT:
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ,�'DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT: `� \
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vin I ADDITIONS. & PORCHES SUBMIT:
Y ❑Soffit SIDING/SOFFIT/FASCIA �. Site Plan/Surve showi the existin strvctures
❑ Other�num O Trim REMOVED? 0 YES O NO �d proposed project. � g
❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
USING TH�l�,Q97 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ ��5.��. � ._ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ See Back Page for Fee Schedule
$ 65% of Building Permit Fee '
$ .001 times the total job valuation
$ � S Q .0005 x Permit Valuation Minimum or .50
$ $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ %% , u Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT YALID 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 pe it work is not to start without a permit on site; that the work will be in ccor ce with the
appmved plan in the case of all w e uires vi w and approval of plans.
SIGNATURE OF APPLICANT NAME DATE �"�
APPROVAL INSPECTOR SIGNATURE �! i� i.�,
�'
�
� �
I��ti����� �t:.�IvICt�'Ai., C'F''�`i"��t, •�i�3k iJNT�ERS�'i""t' A'l'�. t�3.�. i��.�i3�.E'Y, h�i?� ��4`�2 •(7�i�) S?�-'�4St� = FAX {.7�S3j S7i-12�+"�
� � � �` 1 4� '# . } � M � M 9Y� � i!
�t t.1fiC��Pvfi�t1G� ��"lc"i� ��E: �'��'�� t1� �iiilii�"�sQ�
requir�� ttt�t �II r�s�ir��ntial building cc�rttt�ctc�rss, remv��i�r� �nd ror�fiers obfiain a sta`te
li�n�� c�nles� th��+ qu�lify fc�r a speci�c ex�mptic�� fram tt�e i�censing req�a'rr�men#s. As
��� o�n�r c�f th� prcapertY �t , Frid�y, 1
�m exern{�t frc�� t�� �t�fie licensinc� re€��irement t��:ly if !�rn nat bu��d�n� �r imprt��ing
th�� �rc�perty� f�r p�rpas�s c�# r�sa�e. B�y sig��n� t�i� c�ocurr7�r�t, t at��t tc� the f�ct th�t I
am im�rc�vir�� thi� h�rus� f�r my av�n us� ar�d �#c� n�� int�nd ta s��f 'rt. E here�y� c�irn %
!� ��terr�}�f f�c�m th� state [ic,�s�sing requir+�m�nis be;cause 1 am r�rat in the bu�'rrt�s..s e��
t�uiki�n� s�r r�rr�c��lir�� c�� sp+�culation �r ttar r��l� and th�t ti�� F��use tor v��i�h I am
a�A1�in� fc�t t�i� �rm�t, i�l tk�e �rst re�id�r�t�a1 �tn��iure [ fi�v+� b�ai�t c�r irnprc�v��i irt #he
p��t �4 r�c����, i���a �c�r��rteci�e t��t b��u� I d+� �€�t h�v� a�i�t�; ii�ns�, i€vrfi�i�
�r�y ���h�r�i�'� �i�r� r��ts tc� v,�i�ht t r��y r�t�en�is� h��v� k��� +entit�ed unc�er �inr�.
t. a "! 4, f�'� .
F€ar`�herrn�r�, !�c�nc��ledge �at t t�ayr b� }�ir�rrg t`r��i��ettder�t c�or���a!r� tc� �r�c�rm
c�r�in �s���i� r�f i�� cc�n�i�u�iion c�r ir�prc�v��e�t af ti°�i� h�us� �r�d !��d�r��a�� ih�#
�te t�� t�t��� cc�ntr��tc�rs may be r�t�ir�d tc+ b� [i�nseci by th� St�ie Qf Minn�ia. � ' ,
ur��r�t�ntf th�t un[ic�ns�ed resid�ntiat ca�tr�etrn�, remade�ing, and/€�r r�afing sctiv� `t�
a mistf�m��rsor u���r �'Cir�rre�ota I�w, �rtd th�t f wc�uld farFeit my ri�hts to
r�:itr�bursern�r�E frQrn tt�e Garttr�ctor's Rect�ve� ��nd in th� ev�nt fha# an}r ct�r�t�actars I
f��re �re ur�ti�r��e�3.
.� �-� . �-. ,� . . : -�.- • . � . �
� : " �b #i ! "' ! • ` � i i «
p t i . • "" M � • � ♦ ! "" � � M � � ! � �r E �� �� � M � ` #r
:' d� °i � i i—
� �
., �1,�/ 1 �
���� �-- � - > �--