P - 46291Building BUILDING Permit No.: � b
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vat��ct:41uN
763-502-4977 FAX �
EFFECTIVE 1-1-2011
DATE �j�-%��� YOURE-MAILADDRESS
SITE ADDRESS �'Q�/ SZ1� �fi� � � •
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY OWNER/ NAME: �� �'T�.) �� rt -
TENANT ADDRESS: � ���� /4L /.2' �� CITY STATE/�1�! ZIP�_
PHONE:���, -���� � � S�'/�_
CONTRACTOR NAME: �iC.!/it�) \ jg�� GG�t_i.
SUBMIT A COPY OF STATE LICENSE # (�y $a LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: '� CITY �i STATE�ltZIP_�
INSURANCE PHONE FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH OOF ❑ DRAIN T[LE
❑ DECK SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
TENANCE/REPAIR O REMODELINC
DESCRIBE WORK BEING DONE: r(,�—�� .
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
R FING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES %�� ❑ HOUSE & GARAGE
I . Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of sauctural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
O V�inyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing s4vctures
��_ and proposed project.
0 Other ❑ Fascia 2. Two sets of consuvction plans
WINDOWS � 3. Energy Calculations
IN EXISTING OPEN(INGS OYes ❑No l.00ATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPEN[NG CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES AKE BASLll UN VALUATIUN, INCLUll1NG "1'HL+' CU57' UH' LABUK ANU MA1'EIiIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUA
Permit Fee
Plan Review
Fire Surctiarge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �j,,� .pl� 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 ContracWrs)
$ $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 ( )
$ 4 Make checks oavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pernvt 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 11 0•�' lyre�jy�es review and approval of p���„ A`u �4 �,,�
SIGNATURE OF APPLICANT S�IdC. PRINT NAME Cl�[1` c rR•�sC DATE