P - 39843Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
DATE_S���Z�/ I I YOUR E-MAIL ADDRESS
siTE fw�RESS �� ��SC� rM � 5 S �� 5� P? t 6''� v� ��,,'t�� �-.�'�
THIS APPLICANT IS: ❑ OWNER �`CONTRACTOR
Permit No.: f�� �� ���(�
R ce' �ed B: � r y
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Date ec'
PROPERTY OWNER/ NqME: _ C�.kja�1 � 4' ��,�(,
TENANT pDDRESS: 1 S�� E'\I�� s* �� C[TY ��� 0 l- `r� STATE�"�� ZIP
PHONE: ��, 3 �� � 2� i T
CONTRACTOR
St3BMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
NAME: '�� 1� G iT"�'► �t) 1 r-� �� I.cJ
STATE LICENSE # Z, Cj (a 'Z�i '� � 3 LEAD CERT NUMBER ►� Z �'j j 5(S �( Q( �{ Z S�
ADDRESS: �(� C7 ` �"f"U 7'�'``"z 5'T t,f-� 7 �',rj, CiTY GC�C C=O �Cti-''� STAT�'�� ZIP S�� �a
PHONE fa � 2 2> \ �° � l"I FAX
`�SINGLE FAMILY/NEW CONSTRUCTtON S[ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
O ADDITION ❑ GARAGE(SHED �WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: �❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIIt fIXREMODEL
DESCRIBE WORK BEING DONE: a� p� G� �� � f,..3 � rc� o�� �
SIZE
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
� Other
WINDOWS �/�
IN EXISTING OPENINGS �q�es ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES & �
TYPE OF WINDOW TO BE INSTALLED _
LENGTH
❑ HOUSE ONLY
❑ i-iOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
Q Trim
❑ Fascia
LOCATION OF WINDOWS
5/�cnnz S IZf
NUMBER OF WINDOWS
HE[GHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. 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 $��d � OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
� Curb Cut Escrow
Erosion Control
i 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 Residentiat 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 Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appiy 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 a or w �h r�l�� s review and approval of pl s.
SIGNATURE OF APPLICANT '���Zd:M—� PRINT NAME �1Gk N�IC� � 5'� DATE S�2 S�` (
APPROVAL INSPECTOR SIGNATURE