P - 35829Building
Ins�ectic��s
763=�72-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATIt�N
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
:�'�lI -- �'� /_ �
Permit No.:
�e ti
Received By: '° �
Date Rec'd: �(
DATE f- 2� 1� YOUR E-MA1L ADDf2ESS t-r «��-I I� tne W C,eu►^t�M y i`2 Vbl �1n.� . Co w�
I Jr__�
SITE ADDRESS _ �_�{�°1 U�.�t'wet e w�.ax @ C i�'c� � j, �
THIS APPLICANT IS: ❑ OWNER L9�ONTRACTQR
PROPERTY OWNER/ NAME:
TENANT ,qDDRESS:
PHONE:
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDIIVG
❑ Vinyl
❑ Aluminum
❑ Other
tvAn-tE: 1•1 e cc� Co��t�r,� Kew�.o d.Gli+�
STATE LICENSE # ZOZ �(033 0 LE�
ADDRESS: ��'i � Z �G�C,v�,i c, h7t L� •
PHO�IE Cp �Z- ZU'Z (p'L�Z
SINGLE FAMILY/NEW CONSTRUCTION SI
O TWO FAMILYMEW CONSTRUCTION S'1
❑ ADDITION ❑ GARAGE/SHED
�SEMENT FINISH ❑ ROOF
DECK ❑ SIDING
❑ SWIMMMG POOL
❑ NEW HOME CONSTRUCTION ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
��J �GI'�
LENGTH �', � $ t� WiDTH
❑ HOUSE ONLY
_ O HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
�Soffit
❑ Trim
❑ Fascia
WINDOWS
M EXISTING OPENMGS ❑Yes �No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
J �il' i d(eti STATE k't ZIP 5S `iL I
� CERT NUMBER
CITY V+ G e d i rw, STAT��- ZIP 5538�
FAx 45Z-443-3��4
❑ DRAIN TILE
❑ OTHER
Zu
�� cn FT ��
BASEMENT REMODELING SUBMIT:
t. Existing Fioor Ptan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION MCLUDiNG DECKS,
ADDITIONS. & PORCNES SUBMIT:
L Site Plan/Survey showing the cxisting structures
and proposed project.
2. Two sets of consWction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS I
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
SING THE 1997 U.B.0 FEE SCHEDULE) �
COTAL JOB VALUATION $ � 3�� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
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)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks aavable to: Citv of Fridlev 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 o the Ciry of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit ' not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all worl ' r iew and approval of plans. rf
SIGNATURE OF APPLICANT RINT NAME L�f`i� �• l�l.!a�.I � DATE 1' 2(�, -� I
APPROVAL INSPECTOR SIGNATURE :'1
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JOHN J. RY AN CO.
i595 SEIBY AVEi�JUE, ST. FAUL 55104
SCALE: i INCH_._ .�_ .._.______--_ -FEET TELEPHONE 646-&85E
P�..,Ai O� SUR`�EY
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CERT'IFICATE �UF I.�CATION OF E3LJIi�DI�+G
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I hereby certify that on y__ __.lf _� .__.. _._.. ... . t i �.= `-'
CMs sur�ey, pian, rr report w�s prepuce��' by r,ie �:�� cnc!c•� :r��
direct supervisic�n ez��', ih:�t i am 8 dul�' YNgi4tere�, !.an�a �t;r
i�eyar und�; chr ia,aws oE the ti�a�r. cr#"4i,lnnrqoca
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CERTIFICATE UF SI.;RV�Y
[ ne*,�t,� rertifv ehzit or. _ . ,,,
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riiic surcey, pinn, �ir re�urt wa; pr�rpared by me or under mc
iiirecr �upErvision ar�:i1 ch��� f�im a dufy }�egistered Land
�ttr:a�}.�r under the ;aw, n{ the S�atc ��1 Minne�!a.