P - 47799Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.: W� I� U� 5 �
Received By: ��
� R.��
DATE `r� --`� �� YOUR E-MAIL ADDRESS �Sy9y(,%,�� � ,
��.—,.,��� �Cl � � 1 ��l� 1� � C :� lt ✓
SITE ADDRESS ��/� ,�L( l�r'�) �(L�—r��-_,_�1. —=-��� ��i
THIS APPLICANT IS: ❑ OWNER � bNTRACTOR
PROPERTY OWNER/ NAME:
TENAIVT
ADDRESS: CITY STATE ZIP
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 IMPR(IVFMFnrT
ROOFING
NUMBER OF SQUARES %� ,
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
O Aluminum
❑ Other
NAME: /...(`j �l�/�C 1 .'L.r� �C 1� �� �
STATE LICENSE #�C`� U�-/���7} LEAD CERT NUMBER h a
�l ./�-�l r�y ]'Z�%" /
ADDRESS: ' k ` '"'''"�-^ • CITY� ' ''" STATE�iJZIP�Crjy��
�PHONE �',�'l� "' �" r :— Cr�v�i.< FAX / �� "7��' `�Y�C'� �/3 �
INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES
❑ ADDITION ❑ �',ARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �51(ROOF ❑ DRAIN TILE
❑ DECK C] SIDING ❑ OTHER
❑ SWiMMfNr Pnnr
HOME CONSTRUCTION ❑ ADDITION
ITENANCE/REPAIR ❑ REMODELING
��_ _
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
BASEMENT REMODELINC SUBMIT•
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUD[NG DECKS,
ADDITIONS. & PORCHE SUBMIT•
L Site Plan/Survey showing the existing structures
and proposed project.
WINDOWS 2• Two sets of construction plans
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS 3. Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF F�R WfNDOWS – PROVIDE U-VALUE AND
OPENING CHANGES & MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ (�rriTpeiv�v Tt1TT
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
_$ �%.�,�'�_ 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+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Deternuned by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ �� Make checks paVable 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 applicatio 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 w k�w ' view and approval of plans.
SIGNATURE OF APPLICANT '• ,` PRINT NAMEJ�� 1�'
APPROVAL INSPECTOR SIGNA E �y�� DATE �����
�. • '7fP. �"� � �Y4.ih 3f YAe.n�� ,"»..... . .. .. .. ...... .