P - 39995Building BUILDING Pe�t No.: L(� - �
In�pections RESIDENTIAL APPLICATION Re�ei�ed By: a`5�L -
763-572-3604 CITY OF FRIDLEY Date '
763-502-4977 FAX EFFECTNE 1-1-2011 � " "` ��
DATE %� '� i � YOUR E-MAIL ADDRESS J�!"�- `� 4f\F S C N C� i- i L'. S C G Mr"F I L, �� ✓"l
siTE aDDxESS L/ �J l� 3 �� S � dV' 1� ��L � O � L�j r� � 3� `� � r
THIS APPLICANT IS: ,�COWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: j�1� `��'�r�k S G i-( � t- �Z: S
TENANT ADDRESS: �1 GJ /� .� i� _�si �L CITY �'L f� L-L�i STATE�ZIP SS�-/�L
PHONE:� l � —� � -fjl— (2 l �/ �
CONTRACTOR NAMB:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUNLBER
AND CBRTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE pHONE FAX
PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGElSHED ❑ WINDOWS
� BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING Ls X�S'1 r-r u(j �o u r..�
DESCRIBEWORKBEINGDONE: �1'--Y�oO�-- Lk�Sile-,v (S/��„��Up.q
SIZE OF IMPROVEMENT ,� Z� LENGTH � �� WIDTH � 6�� HEIGHT �(�� SQ FT � 7
ROOFING ❑ 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 ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of conshuction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes ❑No LOCATION OF WINDOWS WC jT S rp� FOR WINDOWS —PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & A
TYPE OF WINDOW TO BE INSTALLED �S L-c=� GK NUMBER OF WINDOWS •L
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR ANll MATEKLALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ a OOC1 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
$ G� �1. � S
$ �/S'.�!
$ ,nv
$ . Uc�
$
$
$
$
$
$
$ °i�' •�4."1.2
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 (
checks payable to: City of Fridle.y Attach
�
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pernut and I acknowledge x�at the information above is complete and accurate; that the work will be in
conforrnance with the ordinances and codes of the City of �' 'dley and with the Minnesota Construction Codes; that I understand this is not a
pemut but only an application for a permit and k is t to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all ��r 1 ire's r v' and approval of plans.
SIGNATURE OF APPLICANT �. ��---� T NAME_�� SCIHo 4iZS'� DATE��a I�b I f
A DDD /1V A T TATCDB/`Tl1D Ci!_Ai A TT 7DL' .
' PLEASE NOTE: SEPARATE PERM�`S A,RF�'REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK