P - 45716Building � BUILDING Perrnitivo.: � `i.����j`
Inspections RESIDENTIAL APPLICATION Re�ei�e�, By: �' �r
763-572-3604 CITY OF FRIDLEY nat�e�e�'c�:'� ����`�1�
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE �«- Z�' —)1 YOUR E-MAIL ADDRESS �S,�A� v\ ��Q�l�'� C4`Y''1'�
. .. . •� . . , _.__
SITE ADDRESS _
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
(bjOWNER ❑CONTRACTOR
NAME:_ �� vw � \ J� 0�
ADDRESS: � �,� W �14x,.1 �.�j<
PHONE:
NAME:
STATE LICENSE #
ADDRESS:
PHONE
❑ SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FIN1SH '�tOOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
CITY �1�.f�__STA'
LEAD CERT iViIMBER
CiTY
FAX
SIZE
STORIES
❑ WINDOWS
❑ DRAM TILE
❑ OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: jew/ t4 � ol+ �Q �
SIZE OF IMPROVEMENT LENGTH WID
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �'�� I� HOUSE & GARAGE
GARAGES �TTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
PROPOSED HEIGHT:
SIDING
� Vinyl
❑ Aluminum
❑ Other
�, WINDOWS
` IN EXISTING OPENINGS ❑Yes ONo
�� OR FOR NEW OPENINGS-DESCRIBB SIZE OF
OPENING CHANGES &
❑Soffit
C] Trim
❑ Fascia
LOCATION OF WtNDOWS
HEIGHT
ZIP-����37
ATE ZIP
FT
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDING 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.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $ ��UZ� ��E 1997 U.B.0 FEE SCHOCCU ANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totat Due
$ ---rl -�---? S
$
$ U31,
$ �- j
$
$
$
$
$
$
$ � �
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the tota] 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 payable to: City of Fridtey Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a buitding 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 permit and wor ' 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�Jxich reyuires r w approval of plan .`
SIGNATUR�OFAPPLICANT PRINTNAME �j�j� �ti�� /' DATE �0�2}- �I)
APPROVAL INSPECTOR SIGNATURE i,