P - 41212Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.
Received By:
� ��r- ' ` •
DATE l^�� ^�! YOUR E-MAIL ADDRESS (1 yA^� Pt'�i5a t� �� C(.�f . CO.t�
SITE ADDRESS 7 S( a �Cn.4pQ ��1!`,I' AJG
THIS APPLICANT IS: ❑ OWNER
PROPERTY OWNER/ NqME: � 2,� ✓'n��•-J
TENANT ,qDDRESS:_ �T S( L�S '�,2.n+�a '%��,/- CITY l/'� � STATE��IJZIP � S�3 �
PHONE: �b� - %�Y '� � S ? �F
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATB OP
INSURANCE
PROPERTY TYPE
NAME: Mu : �"(Y',.H CWC-C TZr-2 �
STATE LICENSE # � o�L6 ( 4�r �
ADDRESS: `-(� ��„ VC. �(`S��'�'`�
PHONE (fp� �' S�lO ^ (e�y�
�[SINGLE FAMILY(NEW CONSTRUCTION
�O TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE O ADDITION ❑ GARAGE/SHED
❑ BASEMENT FIN15H �}200F
O DECK ❑ SIDING
❑ SWIMMING POOL
tiL
LEAD CERT NUMBEF
L /'" t! CITY�
F� ?6�-'
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: I O NEW HOME CONSTRUCTION ❑ ADDITION
Cl MAINTENANCE/REPAIR �TREMODELING
DESCRIBE WORK BEING
SIZE OF [MPROVEMENT
ROOFING �
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ A{uminum
❑ Other
se. K„V O
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
N°`f' `�/�`f'!'
�
STATER�+ Z1P��
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Pian
2. Proposed floor plan
3. List of struc?ural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
�Soffit ADDITIONS. & PORCHES SUBMIT:
L] Trim 1. Site PlanlSurvey showing the existing structures
� Fascia
and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Ca{culations
IN EXISTTNG OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
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 $ ����' 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
$ �_�"� Z�
$
$ ,�
$
$ ��U
$
$
$
$
$
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 (Pfans 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 VAL1D 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 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 or <� ic equires review and approval of plansn q �+
SIGNATURE OF APPLICANT i PRINT NAME X y�c..� �4"�''� �t DATE C'�. `T "'��
APPROVAL INSPECTOR SIGNATURE