P - 45098Building
Inspections
763-572-3604
763-502-4977 FAX
DATE G ' J `- ��
SITE ADDRESS �
THIS APPLICANT IS:
BUILDING
RESIDENTIAL APPLICATION
CITY �F FRIDLEY
EFFECTIVE I-1-2011
uJ'ti�J� .
❑ OWNER
YOUR E-MAIL ADDRESS
,1�CONTRACTOR
PROPERTY OWNER/ NqME: CGt'� } ,� ;-(c,�:�.etn,
TENANT ,q�DRESS: ��i� V�+^ 13(rt'c� � . ,�lr �
PHONE�� `7$� yci,jS
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
I+�S ,
Permit No��
Received By: ,'
STATE LICENSE #�D,j y'%�, l� LEAD CERT NUMBER r
9 /
ADDRESS:Z,(��'I�l C'�%'�l ✓1��i .S�_ /1� C"' C[TY C�-� �f� Y
PHONE�Z-` t� �_��% S— FAX %G 5' ��.�`-3J u�
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGElSHED � WINDOWS J- �p,,;;s
❑ BASEMENT FINISH ❑ ROOF L7 DRAIN TILE
❑ DECK ❑ SIDING Q OTHER �� � ��� C
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
DESCRIBE WORK BEING DONE: W!�r��G�;,� S� 17r��7� — i
IMPROVEMENT
ROOFI]VG
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HE[GH7':
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS es �No
OR FOR NEW OPENINGS- ESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED��- ��,Yv� NUMBER OF WINDOWS � CS �
ALL FEES ARE BASED ON t�ALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USIN.G THE 1997 U.B.0 FEE SCHEDULE)
'��D �' OCCUPANCY TYPE
❑ ADDITION
S;
❑ HOUSE ONLY
❑ HOUSE & GARAGE
d ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS � �I o� -�- �_�`
( � ',
HEIGHT
STAT��ZIP $J`��,�.5 Z.-
�'/._. �L�, -- 'Z..��`���
'4 .'; : i �� :
_STATE��n ZIP . Cj%%
FT
BASEMENT REMODELING SUBMIT�
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT30N 1NCLUDING DECKS,
ADDITIONS. & PORCHES SUBM]T
L Site Plan/Survey showing the existing structures
and proposed project.
2. Two seu of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
COTAL JOB VALUATION $ _ ,
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ / `� � �-.
$
$ "
$ �; ; c -��-
$ � _l (�LJ'
$
$
$
$
$
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$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN71L PROCESSED
I hereby apply for a building permit and 1 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 peG it a�fd� 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 wo ' review and approval of plr� T> J
SIGNATURE OF APPL3CANT = PRINT NAME_/� vy �) /(��d�. DATE �J" `l`^" �
APPROVAL INSPECTOR StGNA RE . 'y/ i