P - 45730Building
Inspections
763-572-3604
763-502-4977 FAX
', DATE � O� L
Tr—
SITE ADDRESS
( ' �J
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE I-I-2011
Permit No.:
Received By:
, • - ,Giiw�fii r[. .a 1
��rr� • ' _ �
YOUR E-MAIL ADDRESS (J(jl LP ,S�G2Stiv� � p�%�I � �%�'��- C�M
THIS APPLICANT IS: ,�'IOWNER ❑CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NANtE: (j � 7t�F 17i (._., N�it4% �S 7/�-
ADDRESS: %j.��/���Sa�/)%� �j N�(, C[TY_ Ff��dC�,� STATE
PHONE: � � 1 � %V °l (p s� �j
NAME:
STATE LICENSE #
ADDRESS:
PHONE
❑ SINGLE FAMTLY/NEW CONSTRUCTION
O TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
❑ GARAGE/SHED
.0'1�OOF
❑ SIDING
❑ SWIMMING POOL
CERT NUMB
FA.X
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
❑ NEW HOME CONSTRUCTION ❑ ADDITION
��AINTENANCE/REPAIR ❑ REMODELING
ZIP '��
STATE ZIP
DESCRIBE WORK BEING DONE: (LD�
SIZE OF [MPROVEMENT_ LENGTH WIDTH HEIGHT _ SQ FT
ROOFING �
NUMBER OF SQUARES� L
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF W.INDOWS
NUMBER OF WINDOWS
BASEMENT REMObELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS, & PORCHES 3UBMIT:
]. 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.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
$
$ .,�.
$
$
$
$
.
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$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: Citv of Fridlev
Attach
THIS IS AN APPLICATION FOR A PERM]T-NOT VAL[D 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 work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of' 11 w a__ 'ch '�.e view and approval of plans. J
SIGNATURE OF APPLICANT �- "" " "" PRINT NAME ;� ���/� L/1�!-�%fbf5//-� DATE J O/?�//(
APPROVAL INSPECTOR SIGNATURE .