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Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY va��'d�� � �
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE �"' ���.- �-i% � 0 YOURE-MAILADDRESS�y�.��_1" C�'�`��.���i C.�.'�''r'Ci°v���l .. C` `ll'Y'1—
SITE ADDRESS ��{�71 v t^ i1 �7 *'P'�� �J�
THIS APPLICANT IS: ❑ �WNER �ON'I'RACTOR
PROPERTY OWNER! ��: �t\�,�,f--� 4� � t s�-ti�'�-�
TENANT ADDRESS: ��'-� � i V c_� ' •:�y' �r'� F� c�TY �..��'��J______sTaTE MN z1r � J�i32
PHONE:
CONTRACTOR rtAlvtE: N �� '' � � '�� % ' -�4�.;t: � �
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENS #` L.<<� �'�,� ��.,"i LEAD CERT NUMBER ���T '-'—�� 1--�CJ �— �
AND CERTIFICATE OF ADDRESS: �, u� �, '�iC�iCi\ �� .�i'�: CITY " 1�� '' STATE �vSt�CZIP Sjr-a�:'�i1�
INSURANCE PHONE ` �'� _ ��. � 1— `.� � F,�Y � � �3 _ •�� a �_ C_� z� -
PROPERTY TYPE ❑ INGLE FANIILY>'NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTJON STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WI[�IDOWS
❑ BASEMENT FINISH �ROOF ❑ DItAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CQNSTRUCTION ❑ ADDITION
A[NTENANCE/REPAIR ❑ REMODELING
�
DESCRIBE WORK BEING DONE: � 1��' ��� ���` ("��l(� t�� �- i ���?[
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT 5Q FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �� �HOUSE & GARAGE BASEMENT REMODELING S[JBMIT:
1. Existing Floor Plan
GARAGES �ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of conshuction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes �ATo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPEI�IINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CfIANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE CUST Ur LABUK AiVll MA1'E1ZIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ �°� Ci"� .. r'� 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
$ (I��t "L�
$
$ �
$
$ S
$
$
$
$
$
$ �i�t. r�
See Back Page for Fee Schedule
65°l0 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$25=$
$454 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavabie to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN'I'IL 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 wark will be in accordance with the
approved plan in the case a� wLo_��rl� whic� requires review and approval of pl s.
SIGNATURE OF APPLICANT � �.�------ PRINT NAME �_ }�K'1t'�v"� (� ��;,,:lt�c�hc'� DATE �' ��: � t
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHAr1ICAL WORK