P - 35590Building BUILDING Pe��t Ivo.:��l I�-� ��1��
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY vate xec'd: �7 i
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE �" �p - �( YOUR E-MAIL ADDRESS C�(�E% L( l j� ��(� �? jl�l`�1f . C��'%�l
SITE ADDRESS _ _ _ 7s � � � ,S� �, �'
THIS APPL[CANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: f � � Ii£ p�G'j
TENANT ADDRES-S7: 7� . �i%E CITY F/�/LS E. j( STATE�ZIP .S S y� Z
PHONE: (�.3 � 7 �02 ' ��p�
CONTRACTOR NAME: ��1,(% ��.ey'iDiS %y �A- ��' -
SUBMIT A COPY OF STATE LICENSE # p� �S 9,3fi],S LEAD CERT NUMBER �v A"T '
YOUR STATE LICENSE n_,.,_
AND CERTIFICATE OF ADDRESS: JO�� I q3 �� t�2 _�. CITY {Y�/)% �/�'idF STATE�'(i(/ZIPSS 36
INSURANCE pHONE ?�3 - 3►� - 8'� o� FAX 7�0 ` /S - S 7��
PROPERTY TYPE INGLE FAMILY N SIZE
❑ O FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ A��177otv ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF p DRAIN TILE
❑ DECK ❑ SIDING p OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: - �P��U
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ��% ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT
NUMBER OF SQUARES `J �HOUSE & GARAGE 1, �xisting Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED.SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
I IN FOR NEW CONSTRUC'TION 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 construction plans
WINDOWS 3. Energy Calculations
IN EXIS77NG OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NBW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
a�.� r r,�,a ,�ut� �sE►��u uN vA�UA 1 iViv, livC;LUUIIV(� l�H� (:U5"1' UF LABUK AND MATERIALS:
!, (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surchazge
Suroharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk 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
$ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determinati
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ ��T� Agreement necessary ( ) Non Necessar,� ( )
�j' �/
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on)
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 d codes f the City of Fridley and with the Minnesota Construction Codes; that I' understand this is not a
permit but only an application r ' and work is not to start without a pe it on site; that the work will be in accordance with the
approved plan in the case of a uires review and approval of plan . -� % /
SIGNATURE OF APPLICANT PRINT NAME L�SS DATE !'�� �[�
APPROVAL INSPECTOR SIGNATURE