P - 40845Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� � l- � �
SITE ADDRESS
BUILDING
RESIDENTIAL APPLICATION
THIS APPL[CANT IS: ❑ OWNER
CITY OF FRIDLEY
EFFECTIVE I-I-2011
YOUR E-MAl1,�ADQRESf
1—l(.1��_._ f-� c� r i
Permit No.:+� � � � "
Received By:
Dat����'d�,�
PROPERTY OWNER/ NAME: ;`� �� � �1, �— ,
TENANT
ADDRESS: 1 Z-I �/ .�' ;%;' !i: �(1� �-^f' �� �'�- CITY r �� i � STATE `�� �' ZIP
PHONE�� � �i — `> t � C' E `� �
CONTRACTOR NAME: �•�� c; t i�i� _j C C' +�S ''� d+� t-� t.� � L, �
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # `� 3�� LE.4D CERT NLiMBER
AND CERTIFICATE OF ADDRESS: ���� �i ��' v c't( .�� i' ��� C� � CITY�� �: t.a 'i_"4` c, STATF���ZIP �r,. I ��'�
INSURANCE PHONE �� �� � "- tJ���_� � `�%� C � FA?C
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUClION SIZE
O TWO FAMILY/NEW CONSTRUCTION STORILS
PERMIT TYPE ❑�DITION ❑ GARAGE/SHED � WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILF.
❑ DECK ❑ SIDING ([30THER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR :B:REMODELING
DESCRIBE WORK BEING DONE: � 1` � f'++ �
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES ___
G.4RAGES
PROPOSED S17_�:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
�rCr:: �v�� � <. ,� �
...:�v�:�
LENGTH
❑ HOUSE ONL.Y
❑ HOUSG & GARAGE
❑ AT'1'ACHED GARAGE
❑ DETACHED GARAGE
/� (�.ol Y' "� .- I'��rl.� I C�C :7 � QC �Yic'. rCi I �✓I�
W1DTH HEIGHT
,_>t�7 �1 �- i
FT
BASEMF,NT REMODEI.ING SUBMIT:
I Existing I�loor Plan
2. Proposed floor plan
3 List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS_ & PORCHES SUBMIT:
❑ Trim �. Site Plan/Survey showing the existing structures
❑ Fascia
and proposed project.
2, Two sets of construction plans
�7NDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No 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 �'"`-� C�?���� �• } NUMBER OF WINDOWS -�—
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
USING THE 1997 U,B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ ��' .'z, � c�`C C""— OCCUPANCY TYPE
Permit Fee $ '-� ;' y' � See Back Page for Fee Schedule
Plan Review $ �.'' ;; 65% of Buildin� Permit Fee
Fire Surcharge $ �j `�L; .001 times the total job valuation
Surcharge $ r=(�5,� 0005 x Permit Valuation Minimum $5.00
License Surcharge $ ;,'; ,� $5.00 (State Licensed Residential Contractars)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for detennination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ i. ti;i' Make checics navable to: Citv of Fridlev Attach
ulations
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 ���ork will be in
conformance with the ordinances and codes of the City of Fridley a d with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and wo �is not t�i without a permit on site; that the work will be in accordance with the
approved plan in the case of all w�rk r�h;�h_rP��view and a p oval of p ns. 2 � •�
SIGNATURE OF APPLICANT ��� � �+ ,°�� <-� . ' ��� ,�_N/��4 . ' � �� ` � �" � �,.: ��' �.��� �ATE � ,°� `" �'�
AYPROVAL WSPECTOR SIGNATURE — � ',a � �� - �
)�r! �!�i'��
— - — --
PLEASENOTE: SEPARATE PERMITS ARE R�pU D FOR PLUMBING, rLBC1,RICAL AND MECHANICAI. WORK
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