P - 35209Buildin� BUILDING Permit No.: � �� �
Inspections RESIDENTIAL APPLICATI(JN Received B:
763-572-3604 CITY OF FRIDLEY r������
763-5�2-497� FAX EFFECTIVE 1-1-2011
DATE 1-!D " �� YOUR E-MAIL ADDRESS � L CJ Y��jt7�,f / �/� - CO �i
SITE ADDRESS F� I L� E'�� ��%�,
THIS APPL[CANT IS: ❑ OWNER C�ONTRACTOR
PROPERTY OWNER/ NAME: P d -r'
TENANT ADDRESS: �Q�Yi'j� CITY STATE ZIP
PHONE: � 3-� 7 I- o� 3� y
CONTRACTOR NAME: j i ,J ;N(� .
SUBMIT A COPY OF STATE LICENSE # �S�J' S� LEAD CERT NUMBER �' 7 7� V'� �
YOUR STATE LICENSE n �+� ,�,I
AND CERTIFICATE OF ADDRESS: IO 7O j q3 � ff-�" �U. CITY �(4/pl� STATE /�ZIP .5��3 ��j
INSURANCE PHONE (p -3IS- Q� Q'� FAX �-31 S'�i�1' � l�
PRc7PERTY TYPE �^ F_�;v�iL s�zE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADD[TION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
O DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
Tl'PE OF' WORK: O NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: Ci.d� -��i� � i� �
SIZE OF (MPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFIN �� OUSE ONLY BqSEMENT REMODELING 5UBMIT:
NUMBF.R OF SQUARES _ ❑ OUSE & GARAGE �. F,xisting Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plaa
PROi'OSEU SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
D Aluminum ❑ Trim 1. Site PianJSurvey showing the existing structures
0 Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXIST[NG OPENINGS ❑Yes ❑No LOCATION OF W[NDOWS FOR WtNDOWS - PROVIDE l3-VALUE AND
OR FOR NEW OPENING5-DESCRIBE SIZE OF MANUFACTURE STTCKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL Nr;H;� AK�: KA��U UN VALUAI'lON, INCLUDING THE COST OF LABOR AND MATERIA[.S:
USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ fI_ ��D OCCUPANCY TYPE
P�€!mit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$
$
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��
1
See I3uck 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 payable to: City of Fridley Attach
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THIS IS AN APPL(CATION FOR A PERMIT-NOT VAL1D UNTtL 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 o City f Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for it and or �s not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of c r uir eview and approval of plans. /
SIGNATURE OF APPLICANT PRI T NAME ��L �-SS DATE ��l� ���
APPROVAL INSPECTOR SIGNATUR
Pi.��t� NnTR� cRPARATE PFR Rxt �n nu �t tnt�nrrr �r �r�rxr�r ei�r �� � �;i� �� s 4. :.