P - 35072�
Building� j
Inspections
763-572-3604
763-502-4977 FAX
DATE R� � �
S1TE ADDRES �y��_�+�^1�
THIS APPLICANT IS: ❑ 0
Pi20PERTY OWNER/ NA1vtE: '
TENANT ADDRESS
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011 .� ,
E-MAIL ADDRESS
ER
Permit No.:
Received By:
Dat � � 4�
ATE�ZIP��y�
NAME: �C14. Kc�OF+'fW C K-Rx'r1oc7,t�,\Ct�a►
STATE L►CENSE #�O� LEAD CERT NUMBER NAT- a5o3y�
ADDRESS:4�� �YCL�.Sin'r C�l� CITY'S�ia�Ouis �►vN, STATE
PHONe a5�- q �5 --t�,�,a FAX CL6? - q�a, - yp9A
PROPERTY TYPE O SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCT[ON
PERMIT TYPE � ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH J�,200F
❑ DECK � ❑ SIDING
❑ SWIM�fING POOL
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � I�tEMOAEL:
DESCR[BE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT;
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ HOUSE ONLY
� HOUSE Rz GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
SIZE
o wiN�ows
❑ DRAIN TILE
❑ OTHER
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
CJ Trim 1. Site Plan/Survey showing the existing structures
d Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes L7No LOCATION OF WiNDOWS FOR WINDOWS — PROVIDE U-VALUE ANb
OR FOR NEW OPENMGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE [NSTALLED NUMBER OP WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
] Q� N�THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 1 n� C`M� �— 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
$ (�; r�.5 See Back Page for Fee Schedule
$ T T�� 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$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � Make checks uavable 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 aclrnowledge 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 �. ' e' and approval of �lan�s. `i �1 � 1 �� � Q� 7� � 1
SIGNATURE OF APPLICAN � 5 PRINT NAME `��1�I lCl V t 0► n1c,Q S DATE C� U C� � �
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK