P - 47965Building BUILDING Permit No.: �� ���� C�-���'
Inspections RESIDENTIAL APPLICATION Rece�' By: �
763-572-3604 CITY OF FRIDLE nate'R''e�: " �0�
763-502-4977 FAX y
EFFECTIVE 1-I-2011
DATE �/! �� YOUR E-MAIL ADD{2ESS ��'�1��`c_„y' Chv�tS'�icastS S+@"(C, GL�avL_
S[TE ADDRESS �5�� Z— ST_ �. �, �.,dlEy pu�
THIS APPLICANT IS: ❑ OWNER �7CONTRACTOR
PROPERTY OWNER/ NAME: -Td � /��/Q`S
TENANT pDDRESS: �fSyC� Z� �� N•t1„ CITY YrC(,�1�� STATE MN ZIP SS�Z/
PHONE: 7��-- SS3 —�l (v I
CONTRACTOR NntvtE:_ ��T,S�r,z�s. �',c�C�
SUBMIT A COPY OF STATE LICENSE # 37 � 2 LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: /Y d�u ���,� i(a CITY �5 STATED1�n( ZIP SS3/ 7
INSURANCE pHp �fSo?-y7�'"7GU FAX 9sa-�7o-zay
PROPERTY TYPE INGLE FAMILYINEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SW[MMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
fr3-�INTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE: 1PC� ��oF L'/K� T O�Q /�� U� C1Ce�Jir' 2r ��
SIZE OF IMPROVEMENT LENGTH 33 � WIDTH Z.6�— HEIGHT 2�'� y SQ FT IlDU
ROOFING .ef HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES << ❑ HOUSE & GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Softit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROV[DE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL Nr:L+J AKL�' 1fA5r;ll ViV VALUA'l�lUlV, 1NCLUllING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
$ ,�9�.f,^ �
$
$ ,�
$ .�' � � _
$ ,� C.�
$
$
$
$
$ ,��
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 payable 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 the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f r a per it 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 work ich requires review and approval of plans.
SIGNATURE OF APPLICANT ._.--,- PRINT NAME �'t.t� : � DATE � �7 , ��
APPROVAL INSPECTOR SIG U _