P - 45839Building BUILDING Permit No.• � �
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date '� w ��
763-502-4977 FAX ��'-*�-�: . _, �
EFFECTIVE 1-1-2011 � -
DATE__ � ��p�. ti— ` � � YOUR E-MAIL ADDItESS �.� � /�� J �� �� � '`*� c CLy'�.-.y _
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
❑ OWNER
NAME: � CSr�v\����.t�x—C--L,
ADDRESS: S�� % �,�fl<-• C t� CITY
PHONE:
N.a�E: i5 �..s
STATE�ZIP
STATE LICENSE # �� y�j J LEAD CERT NUMBER
ADDRESS: , 3 I C� �� �/�v� %1��� CITY �/�..�, C.�/�STATE�i�IP��[
PxorrE °7F�3 - �% �3 �- �S`n � FAx �� '3 -- Y� � �- � 3�' �?
�aINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE ❑ ADDITION
❑ BASEMENT FIN1SH
❑ DECK
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING �� s �
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 CHANGE$ &
TYPE OF WINDOW TO BE INSTALLED
❑ GARAGE/SHED
,LCROOF
❑ SIDING
❑ SWIMMING POOL
❑ ADDITtON
�:kEMODEL
b r..-'L'<< �
� HOUSE ONLY
�CHOUSE & GARAGE
�ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
SIZE
STORIES
❑ WINDOWS
❑ DRAIN T1LE
❑ OTHER
G
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION RJCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
l. Site Plan/Survey showing the exis[ing 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)
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
���
��il
���
E��rTI�
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 aavable 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 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 w k which reGuires review and approval of plans,p ,.y� / / �� a� �!
SIGNATURE OF APPLICANT '� PRINT NAME (/ � 7'��C� L� DATE �
APPROVAL INSPECTOR SIGNATURE