P - 36042Building
Inspections
763-572-3604
7b3-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECT[VE 1-1-2011
DATE g /- oZO�� YOUR E-MAIL ADDRESS
SITE ADDRESS '7.��'S Trc.c pp �2 ZGc C�
THIS APPLICANT IS: O OWNER ❑CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
' DESCRIBE WORK BEING D01
SIZE OF IMPROVEMENT
R FING
MBER OF SQUARES
GA GES
P POSED SIZE:
OPOSED HEIGHT:
i
,' IDING
❑ Vinyl
❑ Aluminum
❑ Other � /r Ce,ti<.J�
Permit No.:
Received By:
Date Re�r�
ADDRESS: ��J�S -T�-�O �/���- CITY f't /d�'t �L• STATE ZIP,
PHONE:
NAME:
2�0 2S /w G
STATE LICENSE # D�-D oZE� � i-v�-7 LEAD CERT NUMBER
ADDRESS: �(�!� /,�5� Gt r.c.. /I�w /2a�Yi CITY /« STAT�ZIP _� �C
PHONE ?6�- ?�a - soQ o F,�
❑ SINGLE FAMILYINEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION � GARAGE/SHED L9�WINDOWS
O BASEMENT FINISH � ROOF ❑ DRAIN TILE
❑ DECK Q�IDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR O REMODELING
;: T- a° f� s�cl,�- ��• w�.�a�a u�
LENGT WiDTH
❑ HOUSE ONLY
_ ❑ HOUSE & GARAGE
O ATTACHED GARAGE
O DETACHED GARAGE
L9�So�t
G�'Trim
� Fascia
WINDOWS —/
IN EXISTING OPENINGS 571'es ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES & � �a f �A �s- �
TYPE OF W[NDOW TO BE INSTALLED �vrw c��vs. NUMBER OF WINDOWS
HEIGHT
FT
BASEMENT REMODELMG SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUD[NG DECKS,
ADDITIONS_ & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculafions
FOR WTNDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $��i � 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
$
$
$ ���X-�
$
$
$
$
$
$ R (n 5
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 Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: Citv of Fridlev Attach
THIS [S AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the inforrr►ation 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 wor whic r uires review and approval of plans. / �� �y
SIGNATURE OF APPLICANT � � ��(� PRINT NAME ��r ��F�T-/dr,N�,c� DATE d— � O�0/�
APPROVAL INSPECTOR SIGNATURE