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Building BUILl�ING
Inspections RESIDENTIAL APPLICATION
763-572-36U4 CITY OF FRIDLEY
763-SU2-4977 �AX EFFECTI'VE 1-1-2011
DATE J'(� �� _ YOUR E-MAIL ADDRESS L/ ,� L I S
SITE ADDRESS C.( ��� �.Pr1 [.G(J�� �, � i"{ ('�
THIS APPLICANT IS: OWNER �ONTRACTOR
PROPERTY OWNER/ N�: C�,�GG,I � C� lli I iJG�s'i'IZP� '
TENANT ADDRESS: CP �CpO � �I�ZP � • �. CITY �i,(C� ,l / '
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICF.NSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
o��rr�
STATE LICENS/E # l'fC (JCJ! / Y,O LEAD CERT NUMBE /
ADDRESS:__7 7 y�O /% W. CITY �
PHONE ��� - ���� - p��p ��Q FAX �
{,YSINGLE FAMII,Y/NEW CONSTRUCTION SIZE !
(� �WO FAMILY/NEW CONSTRUCTION S'
O ADDITION O GARAGE/SHED
O BASEMENT FINISH ❑ ROOF
❑ DECK �SIDING
�'� SWIMMING POOL
❑ NEW HOME CONSTRUCTION O ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
/ a� �w, :a7��-
,. � -�--- ------
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
O Other
wnvnows
rpt F�creTm?� QP�TIINrS ❑ve� nN�
OR FOR NEW OPENINGS-DESCRIBE SIZE O:
OPENING CHANGES 8c
❑ HOUSE ONLY
O HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATIQN 4F W?NDrJWS
Permit Nb.:
,,
Received By: �
Date IZ�c1d:_ . _ _
❑ DRAIN TILE I
0 OTHER I
HEIGI3T S FT
BASEMENT tEMOD] LIN(i SUBMIT:
1. Existing Floor Pla
2. Ptoposed floor pl�
3. List of structural mbers to be used
E,�i ,I �`.L�:TI
1. Shte Plan/Survey
and proposed prc
2. Two sets of cons
3. Energy Calculati
FOR VYP.H'JO«IS - PRO :'S]
MANUFACTURE STTCKE
� TYPE OF WINDOW TO BE INST�I,LED NUMBER OF WINDOWS � '
ALL FEE3 ARE BA�3�D ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALI
SING THE 19�'i �.&C FEE SCHEDULE)
�� VALIIATi4N S '_� o; �O . OCCUPANCY TYPE
Pers�it Fce $� ."Le� See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ �' , �� .001 times the total job valuation
Surcharge $ , i .0005 x Permit Valuation Minimum $5.00�
' License Surchazge $ ,� . $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination;
Curb Cut Escrow $ ft+ 6 ft= ft x$24 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee D.etermined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Dne $ �� r�3y� Mske checks payable to: City of FYidley Atta
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the inforrnation above is complete and accurate; tt
conformance with the ordinances and code of the Ci of Fridley and with the Minnesota Constructior� Codes; that I
permit but only an applica 'on erm and o is ot to start without a p�rmit on site; t the work will be
approved plan in the case all r ' r ' e vi d proval of plans{ � �. 9� ,,
SIGNATURE OF APPLICANT PRINT NAME �Jl�C- �/I T I �"� DATE �
APPROVAL INSPECTOR SIGNA , �
i
0
INCLUDING DECKS,
the existing structures
:tion plans
TJ-�IF.LLJi ."��i3D
)N WINDOW.
tt the work will be in
mderstand this is not a
in accordance with the
.�a.1�.