P - 39373Building
Inspections
7b3-572-3604
763-502-4977 FAX
DATE Gl— �l�i � �G� I (
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
YOUR E-MA1L ADDRESS oCl %�� (� �-�„ �F-� ��
SITE ADDRESS ��� L w�ti� �,.41 4 fa'Vl `J` -�'
THIS APPLICANT IS: ❑ OWNER 6�ONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
1NSURANCE
ADDRESS: ,-�� � �7 � ���`��1� ,►rt.� ��'��-eITY
PHONE: ��� ` S� Z r' � l� 1
Permit No.:��,�� ��
Received By: S J �
Date t��� � � r �
ATE �► °t ZIP
�
STATE LICENSE # Z� �{� G� O 3`� LEAD CERT NUMBER
ADDRESS: ��`� 1 y!�, � v, S F` CTTY � ���-� STATE�ZIP—�a��
PHONE GI�Z.. � �l ��I, —d7J'� FAX �"
PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE � �DITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ S1DiNG
❑ SWIMMING POOL
SIZE
STORIES
� WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITfON
1 � MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � c> �I ;�� � W�1.�.�/,S G Y. LC��J �v- G�/� �
SIZE OF
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SiZE:
PROPOSED HEIGHT:
i] HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
SIDING FOR NEW CONSTRUCTION fNCLUDTNG 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 conswction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF � Z'� � Z MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & /�,(5,`s f/�r�!
TYPE OF WINDOW TO BE INSTALLEDA/r,M% I'"wc UMBER OF WMDOWS
ALL FEES ARE BASED ON VALUATION, TNCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION $��_ pc9 O 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
$ v
$
$
$ ��
$---o
$
$
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 aavable to: Citv of Fridlev
Attach Stipulations
THIS IS AN APPLICATION FOR A PERM]T-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 oniy an apptication 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 o �'or�' hi s review and approval of plan /
SIGNATUREOFAPPLICANT �a�i.c.��-t" PRINTNAME �rtuQ i��e��DATE GI"�j� �GJ(
APPROVAL INSPECTOR SIGN�CURE