P - 41881Building
Inspections
763-572-364�
763-502 x�977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
E 1-I-2011
Permit No.:'Zb� � � I��
Received By:_�� r1+"
D���,�t� ��
DATE �^� "' �� YOUR E-MAIL ADDRESS /� h p�-�- � �i r''e e� � I�e a v, � a �^e �� d��
SITE ADDRESS �sa7 ���� �� /y1Q/rL_ G(/� J��
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ I NAME:�
TENANT
ADDRESS:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
�
0
NAME: C.� rp e� C_ � e n.v, «e�� �a 7��tn .
STATE LICENSE #__,�� �j 3�G�d�� LEAD CERT NUMBER I
ADDRESS: ! d� ��(r/� P/^S C'� v1 I�, CiTY�
PHONE �i.� � ,2�irJr- �Sr�ST FAX '7t%3 � �id
1�SiNGLE FAIv[ILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYMEW CONSTRUCTION • STORIES
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION
DESCRIBE WORK BEING
OF
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
Q Vinyl
� Aluminum
❑ Qther
O ROOF ❑ DRAIN 7'ILE
❑ SIDiNG f3COTHER
❑ SWIMMING POOL
❑ ADDITION
O REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�Soffii
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
ATEI%I%%ZI�
v� /7'' �
ATE I�LIP���
u�r �arra�e •
��r
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed Floor plan
3. List of strucWral members to be used
FOR NEW CONSTRUCTION (NCLUDING DECKS,
ADDITIONS_ & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing suuctures
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)
COTAL JOB �ALUATION $ J OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Swcharge
Surcharge ,
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
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)
$+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: City of Fridley
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 e City of Fr' ley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and ork is to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all work whi h r�eguire rev' and approval of plan
AP RO AL INSPECT R S GNATU ,� ����� �h P� ��O �e� DATE ��'�� I%
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