P - 48445Building BUILDING
I�s��� ions RESIDENTIAL APPLICATION
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-I-2011
DATE �P r 3 U' ( 1
SITE ADDRESS % �SO �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
❑ OWNER
YOUR E-MA1L ADDRESS
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�ONTRACTOR
eci..��.KG��3
Permit No. ��
Received By: ��
����'��t�N �
QMC�bi
NAME: - M rSC� � � `�- ��
ADDRESS: ��? ���.� ���' j �pLi. �C Z� CITY I S STAT�N ZIP������'
PHONE: ��Z� �S�"y��C3 t� -- �P��r�+��(�►�rr�
NAME C[�-Ff� / EI�%IU�CL /�C� L-L-�
STATE LICENSE # (O 6( Y / LEAD CERT NUMBER
ADDRESS:J��� 'Si.�i1.?�j-�% %2/2: �/. CITY�Jk�%CL�.,�l,� �iC STAT ZIP��
PHONE ''`%J',3"C�E-,V3 C�-lv/Z- IS��AX � � 3- Z-�
l� iNGLE FAMI EW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES (
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
�BASEMENT FINISH IL�,9xtu� ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION � ADDITION
❑ MAINTENANCE/REPAIR �REMODELING
DESCRIBE WORK BEiNG DONE: a-��� �%�LL J�� ,IgHTH' %V�� ""' /�C�i:' %G� �-�T ��
SIZE OF IMPROVEMENT LENGTH %f.� '� /�� WIDTH �! �
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE
' GARAGES ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
, PROPOSED HEIGHT:
SIDING
❑ Vinyl ❑Soffit
I ❑ Aluminum ❑ Trim
❑ Other ❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
' TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
.a r � � l.l.��%b S �IS�f�` /���'LoD�L
HEIGHT SQ FT ��
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. 6nergy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $��5�� D� OCCUPANCY TYPE
Pennit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Pennit Fee
.00] 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 Deterir�ined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley 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
permit but only an application for a permit and work is n art without a permit on site; that the work will be in accordance with the
approved plan in the case of ork wh-t�h �' e r i nd a roval of plans. �,_
SIGNATURE OF APPLICANT s-��--�`� � 'ti �. AI�NAME�It'i�FF}r �� C'��� DATE�'� �
APPROVAL [T�lSPECTOR SIGN T `RE �" '� „� � ��" '> � � �
PT.F.ASF. NOTF,� SF.PARA E PERM7'TS ARE, REOUIRED FOR PLUMBING, ELECTRICAL AND M HAN AL WORK
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