P - 46810Building BUILDING Permit No.:_ �'�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Re���11 �,�� ' �
763-502-4977 FAX EFFECTIVE I1-2011
DATE r ' f.N � 7 �B�I YOUR E-MAIL ADDRESS � %C � /.� i ��� ��..� �
el.���.v .o rt �� -
SITE ADDRESS �l tl7 �v�� Sf ��
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NpME: ��c.z !',..-1( S-:/'<�k ��',�s lY �``�
TENANT ADDRESS: �%6�l % �.-��f S7`/ �G,` CITY �i�E�f'k STATE'z.cf ZIP S�11�/
PHONE: �/b—.S9l— c�z7/
CONTRACTOR NAME: 'vc�-'t,�— Go.s � ' <-�o t � � � <! T�tc
SUBMIT A COPY OF STATE LICENSE # C 6 c� 6`� `I g LEAD CERT NUMBER�.¢T` ����%%N�P: S � l d'�6 •
YOUR STATE LICENSE �J
ANDCERTIFICATEOF ADDRESS: �Y�Y ��i�ir Ssi�rY� �SS�i CITY/�s%.c STAT6�G_�ZiP�
INSURANCE PHONE (�- — d`�- S FAX %i�-- l���-° g���
PROPERTY TYPE �1 SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
,�MAINTENANCE/REPAIR � REMODELING /1O� �cf � -
DESCRIBE WORK BEING DONE: ca �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING �I-IOUSE ONLY BASEMENT REMODELING SUBMIT:
NLJMBER OF SQUARES �_ ❑ HOUSE & GARAGE l. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calcu(ations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE 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 FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 3_.3QO' �� 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
� �-�_� � 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 C,�(,J $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 Fridle_y Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work wi11 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 work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all r }c requ�res review and approval of pl� j_ �,/ ��%
SIGNANRE OF APPLICANT `����7��� PRINT NAME 9Lf.�G G/ll,A DATE / l7/�III
APPROVAL INSPECTOR SIGNANRE
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