P - 45394Building
Inspections
763-572-3604
763-502-4977 FAX
DATE (
BUILDING
RESIDENTIAL APPLICATION
SITE ADDRESS �/�� S j-� v�/� �33[�
TH[S APPLICANT !S: ❑ OWNER
PROPERTY OWNER/ I NAME:_
TENANT
ADDRESS:
PHONE:
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
YOUR E-MA1L ADDRESS
Permit No.:
' - - -. : r !�
��•: :� � :,. � �i
���C� CITY 'f"2' �.�t �✓�,,- STATE ZfP
CONTRACTOR N,�,tE: L. �-�rra �r cc.. � w-�� �..� o✓l� �� G
SUBMIT A COPY OF gTATE LICENSE #� U r%.6 S%�� LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: (11 C� i D I�� f� C�-t. CI7"Y �/rt�^'t`'a�-t STATE �NZIP ���
INSURANCE pHONE FAX
PROPERTY TYPE
PERMIT TYPE
� SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
❑ ADDITION ❑ RAG
Q. BASEMENT FINISH ROOF
❑ DECK ❑ SIDiNG
❑ SWIMM
TY.PE OF WORK: �Q NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE: ! Cc�. � U�,� /CL iC�'��
SIZE OF IMPROVEMENT ��� LENGTH
[tOOFING
NUMBER OF SQUARES �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WiNDOW TO BE INSTALLED__
SIZE
STORIES
:/SHED ❑ WINDOWS
❑ DRAIN T►LE
O OTHER
NG POOL
❑ ADDITION
❑ REMODELING
� HOUSE OtJLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑So�t
❑ Trim
O Fascia
LOCATION OF WINDOWS
NUMBER
Y
HEIGHT �O {t
FT
BASEMENT REMODELING SUBMIT:
!. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
COTAL 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
$ �f"1 � d S
$
$
$
$
$
$
$
$
$
$ !% .
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
lations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and t 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 work hich requires review and approval of plan /�/�
SIGNATURE OF APPLICANT �rJ��i PRINT NAME ��G'� l�f7'Ti-CLNC,Ci DATE � ll- �l1
APPROVAL INSPECTOR S[G U