P - 39981Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �' � � ' I
SITE ADDRESS ��_
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
❑ OWNER
Permit No.: � � � ���-"
Received By: � ' r�x �'
Date �'f�j � � �' �, �` � �
YOUR E-MAIL ADDRESS �I.-��d' C�'�:��a�--r—� c T c�-.�
PROPERTY OWNER/ NaME: S4;;t:� Lt�is-c�.
TENANT pDDRESS: CITY
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFTCATE OF
INSURANCE
PROPERTY TYPE
NAME: 1 tz-*'t�.�-+���., l c..
ATE ZIP.
STATE LICENSE # �4 (p ;3'�,� i(o LEAD CERT NUMBER
ADDRESS: %�S^�:3 i3.-t.� •}— ,� �- CITY�C.r. L'� lt STATE �`�^�ZIP
PHONE _ 7� �'" ��'i� 'lGS �j FAX
.E FAMILY7NEW CONSTRUCTtON
FAMILY/NEW CONSTRUCTION
PERMIT TYPE � �DITION ❑ GARaG
❑ BASEMENT F[NISH �ROOF
❑ DECK ❑ SIDING
❑ SWIMM
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF [MPROVEMENT
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCEfREPA1R
ROOFING
NUMBER OF SQL)ARES �_
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 WMDOW TO BE INSTALLED
SIZE
STORIES
�(SHED ❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
NG POOL
❑ ADDITION
d REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
WIDTH
HEIGHT
FT
BASEMENT REMODELING SUBM17':
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction pians
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:
(USIN THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ � ,('} 0 OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Dae
$ '7� ,%� �,5 See Back Page far 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 Pian Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: Citv of Fridlev
Attach Stipulations
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
pertnit but only an application for a rm' and w rk 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 w re ' es review and approval of plans y
SIGNATURE OF APPLICANT PRINT NAME �7'`��'[ �i�( DATE /�'l S'� —//
APPROVAL INSPECTOR SIGNA URE '