P - 47277Building
Inspections
763-572-3604
763-502-4977 FAX
DA
SITE ADDRESS �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-I-2011
`�$,'OWNER
Permit No.:�� � � C� .�
Received By:����J
Date��:� �' �
YOUR E-MAIL ADDI2ESS _ C�YY��'��'-�' YV10v �IL (J,� ,/����� C� y�
❑CONTRACTOR
PROPERTY OWNER/ Nq�E: cl�r�s �f'i r�e 1'Y)e u.�✓
TENANT
ADDRESS. �(�Q� }'Y�1SS 1S,s � P p I $.�- CITY ���/ �.� � STATE /� ZIP S-Sy3 2
PHONE: to I'7_ -% 1 t" � C ..,3
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: CITY
PHONE
FAX
u �wliLt�; h'AMIL EW CONSTRUCTION SIZE_ ��� �-
❑ T O F ILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING J$'OTHER
❑ SWIMMING POOL � � �
❑ NEW HOME CONSTRUCTION ❑ ADD1TlON
❑ MAINTENANCE/REPAIR �'REMODELING
DESCRIBE WORK BEING DONE: C_ q✓�pS
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 & C
TYPE OF WINDOW TO BE INSTALLED G�;
�4
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WI D��% S
�.�..5� .SIC� C� F'C4"�(,Q9- �'} .
NUMBER OF WINDOWS
ATE ZIP
FT
BASEMENT REMODELING SUBMIT
1. Existing Floor Plan
2. Proposed floor plan
3. List of struc±ural members to be used
FOR NEW CONSTRUCTION TNCLUDING 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:
//�(j.jSING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION � 4"i` �.� n(`C•TiPAN�''v TVDD
� Permit Fee �
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ s� �� See Back Page for Fee Schedule
$ " 65% of Building Permit Fee
$ ,L L�i .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 ( )
$ o L�.L-- O Make checks payable to• City of Fridle_y Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and T 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 w r ' h requires review and approval of p /
SIGNATURE OF APPLICANT ,,Q�yc/` PRINT NAME . y,iSt-)�,� `1/��� ✓—
APPROVAL [NSPECTOR S[GNATURE _ DATE / / 2— / �