P - 35218Bui�ding
Ir"ispections -
763-572-3604
763-502-4977 FAX
DATE�
SITE ADDRESS f
THIS APPLICANT IS:
�
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MAIL ADDRESS __�<'_�, ... �' d•� v'^ i:�.. c' <
T:
"s �.� , "r=;-,;11;-3
❑ OWt��ER E'iCONTRACTOR
PROPERTY OWNER/ NpnqE:
TENANT
ADDRESS:
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
CITY
Permit No
Received By: !
Da��e�'d:� �.� �
��%
1. 4 2 �1'�
STATE ZIP
NAME:y kaz�i., z�1A r i - i::.c 5.��,- �� �">
STATE LICENSE # Z v G� .�;% i% LEAD CERT NUMBER
ADDRESS: ti`i !"/ � I I C�:- ,'- 7 j' ik C1TY �;. � V� i`� STATE ,'� I�Z1P .SS y�f
PHONE t- t 2 ° c'�1 ,�� �% 7�'�- FAX
❑ SINGLE FAMILY/NEW CONSTRUCT]ON SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
pBASEMENT FiN1SH ❑ ROOF ❑ DRAlN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SW1MM[NG POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR Q'{2EMODELING
('iZ�-i `�'i,., )f`� ,sv,�fs:ao � �,.�iLt,� i.i—�5���'YL.... N4w t-i9�L �;7 . e��;;i :/}rL-'cG�.c=
LENGTH ZL ' WIDTH I`� � HEIGHT 7� SO FT
ROOFING
NUMBER OF SQUARES
G.4RAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
��'INDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED_ _
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACNED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOV��S
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3 List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDiNG DECKS,
ADDITIONS, & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Tv,�o sets of construction 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)
fOTAL JOB VALUATION � I; �° t> OCCUPANCY TYPE
Yermit ree
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �j`c�, ��
$ < ��, � � �
� � . U ._
$ ' ,�C.i
$ �—�--=— =
$
$
$
$
$
$ d d �.'
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+6fr= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks �avable to: Citv of Fridlev Attach
lations
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 not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all work wl�ich requires review and approval of plans.
SIGNATUREOF?.PPLICAN'i ' S L. ,� PRINT?�AME---!� �.� 5,., :., .�;�-< J DATE � ��� I`
APPROV,AL I?��SPECTOR SIGNATURE �
PLEASE NOTE: SEPARAT� PERMTTS ARE REQUIRED FOR PLUMBING; ELECTRICAL, AND MECHANiCAL WORK
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