P - 47349Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � '� r L`� �
SITE ADDRESS /S
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY �
-� //�!�* �.'/F3n'/� /�aA�_
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
OWNER
Permit No.
Received By:
Da�' d: � i
EFFECTNE 1-1-2011 i '—" ^
E-MAIL ADDRESS f'�'a,�c ����'i t t� €ZC �T�l�a�` ;� � C_C�/s^
.v. J ,� L l,br1 />,k: .
ADDRESS;� � 3 l �Lr-d'� �'�'��� �` � CITY G�-�d �t' STATE/�^/ ZIP � �
PHONE: /c�-S _ %._/ f - ��G i -
NAME:�/1f�t�i t�l�T�I�lO/(�)
STATE LICENSE # �l%`: � � � ��
ADDRESS�C.�C��' ���IY��'-�Sr� 4�,� �
PHONE �S � ��¢' � � �
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
ADDITION GARA(
BASEMENT FINISH ROOF
DECK I�
�
NEW HOME CONSTRUCTION
MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:%/�i�,/a �- �O�q�s�
SIZE
CERT NUMBER
CITY�� � STATEf�,V� ZIP �1 L�
DRAIN TILE
OTHER
ROOFING HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES HOUSE & GARAGE �. Existing Floor Plan
GARAGES ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS & PORCHES SUBMIT:
Vinyl Soffit �, Site Plan/Survey showing the existing structures
Aluminum Trim and proposed project.
Other Fascia 2, Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS Yes No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
.-: r�.. lUSI11K° THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUA'
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Swcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
ANCY
$ a(J ,,'� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ J/�$ .001 times the total job valuation
$ ,�, '78 .0005 x Permit Valuation Minimum $5.00
$ �', QQ $5.00 (State Licensed Residentiai Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ �+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �3/ � Make checks payable to: City of Fridley 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 City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application fo 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 a r� ich requires review and approval of plans. �. �f •
SIGNATURE OF APPLICANT � ^-'�"/ � - -� PRINT NAME � L� `� �'O''�'� °f'i f� DATE � �� ' Z!) /�
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK