P - 35747BU11C�lrig � $VIL�jNG � Permit No.: ��%� (� (� �
Inspections RESIDENTIAL APPLICATION Receiv '
763-572-3604 ��� -� (
763-502-4977 FAX CITY OF FRIDLEY Date Rec'c1:
EFFECTNE t-I-2011
DATE 1S '�—/ I YOUR E-MAIL ADDRESS
SITE ADDRESS � �'j��,;Qg,/„a.¢,�J�� „p.�
THIS APPLICANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY OWNERI
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
ADDRESS: „eA�„ �,., C1TY
PHONE: d/',2` �.�0—S4�fl
'ATE Z1P
STATE LICENSE #�,ZOO/S'D �R� LEAD CERT NUMBER
ADDRESS: aC U�FD ��i/m, �i 31� CITY�° �.� ��� STATEd(fL_ZIP cS'S p
PHONE �S�/ � �%% %- ��F/i FAX � S%- i%�- �4'7 /
❑ SINGLE FAMILY/NEW CONSTRUCTION S[ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DtTioN
❑ BASEMENT FINISH
O DECK
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
❑ GARAGE/SHED ❑ WINDOWS
❑ ROOF ❑ DRAM TILE
❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CON5TRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR D REMODELING
ROOFING
NUMBER OF SQUARES �
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
0
❑ HOUSE ONLY
B1 HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT(ON MCLUDING DECKS,
ADDITIONS. & PORCHES SUSMIT:
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 $�c��70. � 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
$ ?i "�j.� 5 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 payable to: Citv of Fridlev Attach
lations
THIS IS 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 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 all work,�V hich equ�res review and approval of plans.
SIGNATUREOFAPPLICANT �jLe/E c<��yLQs�l PRINTNAME FR��D �'pii/GroLL DATE � e�`f/
APPROVAL INSPECTOR SIGNATURE