P - 42208Building BUILDING PermitNo.: '�Os
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX ��� � � � �
EFFECT[VE 1-1-2011
DATE �� YOUR E-MAIL ADDRESS �� L/�� �r�� "'� �Covy.
SITE ADDRESS �OG J �' PI�C1L.. /U �
THIS APPL[CANT IS: ❑ OWNER iQCONTRACTOR
PROPERTY OWNER/ NAME: G J�12 vn
TENANT ADDRESS: �UD �� p�cf.u� �� CITY Frc ��iGc� STATE Mr� ZIP SSzF3Z,
PHONE: %�0..3 � 57/ — '��T 3
CONTRACTOR NqME: �tla R�o�t1�q � "R+c�oc�.�►.\i�cya
SUBMIT A COPY OF STATE LICENSE #�O� LEAD CERT IYUMBER N�- a5o3y" �
YOUR STATE LICENSE -
AND CERTIFICATE OF ADDRESS: 4�� F...ytGt��p� ��� CITY'S�.�Ouis �r1R. STATE� ZIP'SS�I:�
INSURANCE pHONE q5'�- �f IS �i7� FAX Ctb� - �1�3 -
PROPERTY TYPE �E9 SINGLE FAMILYlNEW CONSTRUC7'ION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT F[NISH �'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: O f "F �.�� '
SIZE OF IMPROVEMENT LENGT WIDTH HEIGHT S FT
ROOFING r�� ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES v°v 2�HOUSE & GARAGE l, 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 exis[ing structwrs
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. EnergyCalculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE TNSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUA'1'IUN, INCLUUINC: 7'H� CU5'I' UH' LABUK A1Vll MA1 LKIAL�:
US NG TH �j C FEE SCHEDULE)
TOTAL JOB VALUATION $ �� ��� °"� OCCUPANCY TYPE
Permit Fee $ ' See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$24 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Totai Due � ._ Make checks paYable to: City of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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 a work which r uJ�'es r�view and approval of lans. I/
SIGNATURE OF APPLICANT o �Gt�CJ� PRINT NAME�ear� nt �[ �r tic DATE S�'ZI��
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK