P - 39987Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
DATE �' � Z- ' I�
SITE ADDRESS � ��C` �' � ''-'� T�'I'L�
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSt3RANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
G��/�=
CITY OF FRIDLEY
EFFECTIVE I-I-2011
: :
YOUR E-MAiL ADDRESS l7D��1� `c�v1�'Z / G'c
,;;J
Permit No.:`� � t�
Received By:'1 � l(,�1iC'
Da�t�'dS�p 1 �, ����
r
ADDRESS:���) �1,��" CITY �rfL�IY� STATE%Z%�%ZIP J�sy3�.
PHONE: � I Z- "�i i� ��S 7(d
NAME: �✓� r�° �-- � cl•�1t�6Gci�� C� C'S' i> t�f, -�"� ,m
STATE LICENSE # Z�Y � 1-I �P `-! y LEAD CERT NUMBER
ADDRESS: lS �ySG �--�''?��'� .S %�" CTTYl��f��J�:� STATEOZ�R-ZIP��,�t>`
PHONE 7�� S- �/ .� �� — y% Z Z p,q3{
SINGLE FAMILY/NEW CONSTRUCT]ON S[ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED O WINDOWS
❑ BASEIvIENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK SIDiNG ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: C� �� L'<? _ "� l� e J/4C � lZ c���
ROOFING � L,��
NUMBER OF SQUARES �
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 WINDOW TO BE INSTALLED
❑ HOUSE ONLY
C] HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
FT
BASEMENT REMODELING SUBMIT:
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 consuuction plans
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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ /L J, Z�
$
$ �j
$
$ �
$
$
$
$
$
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)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks oavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NO't 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 fo permit and wor is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of a rk w�c rhfi'r e uires eview and approval of p�l �- / G _�
SIGNATURE OF APPLICANT .. � PRINT NAfvtE (°7 �xl�-/ Jtc U`G� � DATE J�!Z I
APPROVAL INSPECTOR SIGNA