P - 42108Building BUILDING Perrnit Ivo.: �(J� Q
Inspections �SIDENTIAL APPLICATION Received By:��_
763-572-3604 CITY OF FRIDLEY nate 1z I1���'` f� �i �
763-502-4977 FAX EFFECTIVE 1-1-2011 ���
DATE '� "=—'?.b i I YOUR E-MAIL ADDRESS
SITE ADDRESS �/ / S �i �� � NE
THIS APPLICANT IS: �OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: f�L
TENANT �D �� j �� � � � 3 •''� ST /�% CITY �f�,F'�/ STATEX/1 ZIP S s��. / �
PHONE: '?�o "�i ` SI � — S�o"7rJ
CONTRACTOR N,�tvtE:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE p,qX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DTTION ❑ GARAGE/SHED %� WINDOWS
❑ BASEMENT FINISH ,{a'ROOF ❑ DRAIN TILE
❑ DECK �SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: (.�3 (� �- /r � /�y. QCO�, $' !.v t e,S 1� t� cs,►,�j
SIZE OF IMPROVEMENT � CENGTH + LL���" WIDTH �� HEIGHT � S FT
ROOFING � ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBBR OF SQUARES Z�v �'HOUSE & GARAGE I. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of swctural members to be used
PROPOSED HEIGHT:
SIDIN FOR NEW CONSTRUCTION INCLUDtNG DECKS,
❑ Vinyl �ga�t ADDITIONS. & PORCHES SUBMIT.
� 1. Site Plan/Surve showin the existin structures
� Aluminum ❑ Tri Y g S
❑ Other � p�$ and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS j8'S'es �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF �/oA/ �M-S,TS�t�t,` lo�+ Sei�%N" �/C� MANUFACTURE STICKER ON WINDOW.
OPENWG CHANGES & / p,t..�b �.,R,eu g�j— 5�p�
TYPE OF WINDOW TO BE INSTALLED ,D � ER OF WINDOWS TAZ,
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(U�T,�1 THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�" 3�°C' r" �� , po o"' __ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$
$
$ '7
$
$
$
$
$
$ w
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the totat job valuation
.0005 x Permit Valuation Minimum $5.00
�5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determinationj
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Bngineering
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 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 work which requires review and approval of plans.
SIGNATURE OF APPLICANT ��i PRINT NAME '�/� � 1/ _ e � �\I DATE �� � � ��
APPROVAL INSPECTOR SIGNA RE T'—