P - 37247Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 75 O I�I Il
SITE ADDRESS a �I �
THIS APPLICANT IS:
PROPERTY OWIVER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
Permit No.: �� (
RESIDENTIAL APPLICATION Received By:
CITY OF FRIDLEY Da��'d��� �, .: ����
EFFECTIVE 1-I-2011
' YOUR E-MAIL ADDI2ESS _�� V/Q/ � f, y✓P.� f��l.t S_ l O�
❑ OWNER
NAME: T✓ C
ADDRESS: C� Gl G I�. `� G✓I��Q l� T�'�°l�CITY 7"�� � ,J� STATE � ZIP
PHONE: 6.5—�— Z�p "' ����
NAME: M�, L+ ` f' � • r �''�i
STATE LICENSE # Z(JQI� Z 7�� LEAD CERT NUMBER ��T^ �? C� ,� I
ADDRESS: �j�L S' ,y LGr �"2 U'•I� ('i � CITY /�0 � � /�'STATE J�� S7'36
PHONE �� � '' '� Z � �-" �� ��j
� SINGLE FAMILY(NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH � ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POc
FAX �
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPA]R ❑ REMODELING
'I DESCRIBE WORK BEING DONE: �'E� �/JS�Q
I SIZE OF IMPROVEMENT LENGTH W2DTH
I ROOFING ❑ HOUSE ONLY
; NUMBER OF SQUARES � D ❑ HOUSE & GARAGE
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
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF W[NDOWS
NUMBER OF
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Exisfing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey 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 $,S1S�(�O OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Contro]
Park Fee
Sewer Main Charge
Total Due
$ �U.Z�
$
$ �" I _,.%
$ �$ �0
$
$
$
$
$
$ � �.�%)
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)
$223Q 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 pavable to: Citv of Fridlev 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 witl 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 �lc which requir e r v'ew and approval of plans. /�_ 1
SIGNATURE OF APPLICANT ��.�� � PRINT NAME �TY '�✓J�1.y (e��ATE �� ���
APPROVAL [NSPECTOR SIGNATURE