P - 39338Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
DATE� '- Lb " ( � ��
SITE ADDRESS 1S :� �N. � m � '" /C
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/ ( N,�1vtE
TENANT qDDRESS: /J jd J� ��`" '"' 1� ��'�
PHONE: �( L%I�(" —� 7 S 7
2
CITY OF FRIDLEY
EFFECTIVE 1-(-2011
_ YOIIR E-MAIL ADDRESS
C l�L
I�ONTRACTOR
j !"C ✓I n� vl
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CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BE[NG DC
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES ^
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
I�3AME:
�C
Permit No.: �Ui � "��� 7 �
Received By: �(,(,� ,
ITY �r"�L�Izy STATEM'�� ZIP,
STATE LICENSE #��(�p,f 5,��'�r��' *� �t•it"'t7c'/LEAD CERT NLIMBER
ADDRESS: �y �l � Gt�l� S �i� u�'� �%v� . �/ CITY /U%�S STAT�`�' �� ZIP -SS�� Z
PHONE Cv � L S 2 Z' Co � G� � pq}{
� S LE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED � WINDOWS
❑ BASEMENT FINISH ❑ ROOF p DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCT[ON ❑ ADD(TION
❑ MAINTENANCE/REPAIR ❑ REMODELING
E: I�C vn oJL v1 C D� ' r.•!c� w�`•, o WS y'e p� CY 1,ts�=f-� C� �4 tS %�%oc G�-'^ bwJ (v, ` l/evi 1"
LENGTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
�Soffit ADDITIONS. & PORCHES SUBMiT:
❑ Trim 1. Site Plan/Survey showing the existi�g structures
❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENiNGS �es �No LOCAT N OF WINpOWS f, �� FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS- ESCRIBE SIZE OF � S� ���,-�Z Y� /�1 MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & I� Js, Q�o _ j/
TYPE OF WINDOW TO BE INSTALLED u`'NUMBER OF WINDOWS �--
ALL FEES ARE BASED O VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ `(i �°'�' 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
$ �,3 :5� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .` (� .001 times the total job valuation
$ �tj .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 pavable 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 ity of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit nd ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case rk w'c r es review and approval of plans. `/ ! �7
SIGNATURE OF APPLICANT � PRINT NAME �tv,��t lYO `��� DATE �a(,� ���
APPROVAL INSPECTOR SIGNATURE 1