P - 39568Building BUILDING Permit No.: �'�' � ��� ���"
Inspections RESIDENTIAL APPLICATION Received By�
763-572-3604 CITY OF FRIDLEY Date R �n
763-502-4977 FAX ����--�� � � � �
EFFECTNE 1-1-2011
DATE YOUR E-MAIL ADDRESS
SITE ADDRESS (� CJO � �-1 r I� S�/ �/�/ �
THIS APPLICANT IS: ❑ OWNER QCONTRACTOR
PROPERTY OWNER/ NAME: �/9 � 17v SC I��Y�, ,�•�
TENANT qDDRESS: ��Q � L�•� h S'� �'I/ Ii C(TY �r� STATE ti% ZIP�S G%7�
PHONE: G��o� — �� ic " �I %K
CONTRACTOR NAME:_S klh-� <
SUBMIT A COPY OF STATE LICENSE #
YOUR STATE LICENSE C
AND CERTIFICATE OF ADDRESS:_�
INSURANCE PHONE 7�.� `
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
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.A CERT NUMBER
C1TYL!/�Y�-L .L�%LC STATE(�ZIP ,�a ')
FAX
CFSINGLE FAMILY/NEW CONSTRUCTION SiZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH I�]"ROOF ❑ DRAIN TILE
❑ DECK � SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTfON ❑ ADDIT[ON
❑ MAINTENANCE/REPAIR � REMODEL[NG
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
ROOFING �
NUMBER OF SQUARES � ��j
GARAGES �/ �
PROPOSED SIZE: �Q
PROPOSED HEIGHT:
SIDING
❑ Vinyl
� Aluminvm
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES Bc
TYPE OF WINDOW TO BE INSTALLED
�
❑ HOUSE ONI,Y
�HOUSE & GARAGE
O ATTACHED GARAGE
❑ D�TACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WtNDOWS
NUMBER OF
� HE[GHT / ,S�G�'�/ SQ FT �—r
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS_ & PORCHES SUBMIT•
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR A1vD MATERIALS:
%/ ( SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ "/ � I� � OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
�i Park Fee
� Sewer Main Charge
! Total Due
$ l l (.G�
$
$
$
$ SZ�
$
$
$
$
$
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= frx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks aavable to: Citv of Fridtev
Attach Stipulations
THI3 IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 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 wil] be in accordance with the
approved plan in the case of al hic e ires review and approval of pla�t, .� /����
SIGNATURE OF APPLICANTp PRINT NAME ��C 1�- 1/ �v+'`�✓� DATE ��' �� ��
APPROVAL INSPECTOR SIGNAT .