P - 47908Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
Permit No.
Received By:
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DATE �o-- � LI� 1l YOUR E-MA[L ADDRESS S� it� �.i} v� Gch S�� �G'��Cn
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SITEADDRESS 7�-j�'1G V..:.n (S�ren 5�✓�� ('r�U1Zy i'hv1 � SLI��-�
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES �—�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
� Aluminum
❑ Other
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ADDRESS: %�-��L(l V,-�n 13v�zr S�' '�� CITY
PHONE: ��0 �'- %� LI - �-� v�i
STATE fNlvi ZIP S� y 3�-
NAME: i�Vr..iO Lcv���Y�G��c,• ._
STATE LICENSE # �.G �p 39 3 tr'S S LEAD CERT NLJMBER
ADDRESS: � 71 t-1 i-\ 1Z�i� �v�i' 7 5� CITY V�-� c�v�. j�c. }ct STATE Mt1 ZIP ti i� o-+�
PHONE �D I�- S�Y, 7fo 1( FAX
FYSINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES i
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH [�'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SW[MMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADD1T[ON
C�MAINTENANCE/REPAIR ❑ REMODELING
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZI�. OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GAnAGE
❑Soffit
❑ Trim
❑ Fascia
LOCAT' � � Or W[NL70v��S
NUMBER OF
�1.V1���:�
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT[ON 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)
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
$
$
$
$ ��$
$
$
$
$
$
$
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 Stipulations
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•,� w r which requires review and approval of plans: /�
SIGNATURE OF APPLICANT ���.CG/ PRINT NAME /f/, c:-�c ���.�i �.,/ DATE (D `�y— ��
APPROVAL INSPECTOR SIGN TURE