P - 48082Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 11-2011
Permit No.z����� ��
Received By•
�ate�Ke�'�:� � O 2 �
DATE l�—,7i'// YOUR E-MAIL ADDRESS � o� �_y/�L�i�C , Cu�
SITE ADDRESS �ns�� /�O/I/0'G S�/(/� !'i,'e��i /`11(/ sty.3Z
THIS APPLICANT IS: D OWNER �'CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
NAME:
ADDRESS:
NAME:
CITY
�ZIP �`'Jry3?
STATE LICENSE # 2ose ��3 �/ LEAD CERT NUMBE , �o� � E�`
ADDRESS: r 1/� /V , C["fY ��'J,fl y__STATFJ'�1✓ ZIP SS.3a3
PHONE ;}-
�B'SINGLE FAMILY/NEW CONS UCTI1
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH O ROOF
❑ DECK ❑ SIDING
❑ SWIMM
FAX t(p S ` 7S
SIZE /0�1C� Sf
STORIES f
.0"WINDOWS
❑ DRAIN TILE
�J'�THER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
J�viAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �. i+ �, .,�
SIZE OF IMPROVEMENT LENGTH WIDTH
R N ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
�ASEMENT REMODELINC �i rR�T•
l. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑So�t SIDING/SOFFIT/FASCIA ADDITIONS_ & POR .HF.. S BMIT:
O Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO �• Site Plan/Survey showing the existing structures
❑ Other ❑ F��a and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ,0'S'es ONo 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:
(USI G T E 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�- �,(}(� _ OCCUPANCY TYPE _
Permit Fee
Plan Review
Fire Suroharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
$ 1 ��.Z 5
$
$ D
$ 5
$ 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)
f�+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridlev Attach
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 no to start without a permit on site; that the work will be in accordance with the
approved plan in the case of work which requires revie nd ap val of plans.
SIGNATURE OF APPLICANT T NAME "3pC. M�it �2 �� DATE //-.� 9�/�
APPROVAL INSPECTOR SIGNAT[JRE i r ./s� _ _. �
N
O
�
N
�
.-�
W
f./�
�
�
�
�
�
�
1�
N
� gs
00 yQ.
N �
N � �-J c�
�
�.
�
2�
�
r_ q•@� � B'5" 12'10" .. .
�
nr•
�
�
�
�
7
.lT�
�
�