P - 45768Building BUILDING Permit No.: ��-� ((� L`;��� t
Inspections RESIDENTIAL APPLICATION Received By: �1�' F�_
763-572-3604 �
763-502-4977 FAX CITY OF FRIDLEY D���� ��� ���
EFFECT]VE 1-1-2011
DATE " � YOUR E- AIL ADDRESS
SITE ADDRESS ��7 i,f�-� t.2 C(`.�,`� �1:2 il
THIS APPLICANT [S: ❑ OWNER _ �ONTRACTOR
PROPERTY OWNER/ NAME: � h,(,L � �'�
TEl�1ANT pDDRESS: }Ctw�- CITY
PHONE:
STATE ZIP
CONTRACTOR rrqME: � �,,1, ►J �,+ T�' f�•,y� z,,� r,,�C�
SUBMIT A COPY OF
YOUR STATE LTCENSE STATE LICENSE # Z� ��.�' 2! 2 LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: J f l �^I Z-BL-�t G.� �{ ;yv CITY CtnCcp�hD cn STAT ZIP C
INSURANCE PHONE 3 � � �S" C� FqX '��, �i � � (, � %
PROPERTY TYPE `'��INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE I ❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
� TYPE OF WORK:
, DESCRiBE WORK BEING
SIZE OF IMPROVEMENT
SIZE
STORIES
Q W[NDOWS
`T�4tOOF v V✓ ❑ DRAIN TILE
❑ S►DING C] OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE(REPAIR ❑ REMODELSNG
, Hr,..._.� ...• �1 _� �Ai
ROOFING
NUII�BER OF SQUARES 3 �
PROPOSED]
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTII�iG OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING GHANGES &
TYPE OF WINDOW TO BE Ii3STALLED
❑ HOUSE ONLY
�.HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
TION OF WINDOWS
OF
WIDTH
FT
BASEMENT REMODELING SUBMIT:
1. Existing Fioor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT[ON INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site PlanlSurvey showing the existing structures
and proposed project.
2. Two 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)
TOTAL 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
$
$ /
$ '
$ �5 �i �
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
A005 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 payable to: City 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 he 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 wil] be in accordance with the
approved plan in the case of a1] wor hich requires r'ew and approval of plans.
SIGNATURE OF APPLICANT __T��� PRINT NAME �f tCi� �-UlU ��.N c��DATE � � ��
APPROVAL INSPECTOR SIGNA RE