P - 36728Building BUILDING Pe��� No.� %� � �
Inspections RESIDENTIAL APPLICATION Received By�b W�_
763-572-3604 CITY OF FRIDLEY ������1� 1� 2�11
763-502-4977 FAX �FFECTivE �-i-zo>>
DATE C7 "' �6 •°��i %� YOUR E-MAIL ADDRGSS 1�c�'C��l/"G�-�lc'-Q i"B,s'Tpi'.c.'fieix.. G CJ,.L��
SITE ADDRI:SS ,.! 7� ,> T�' �� °�.2� �� �/'/(� ��y' ,p��
'I'H1S APPLICANT 1S: O OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: �� �/�e.S'
TENANT ADDRESS: CITY STATE ZlP
PHONE:
CONTRACTOR NAME: ��1.°Q.�" G�e.�/Ge. Resy`o�74'ow.
SUBMIT A COPY OF S�ATE LICENSE # �O6 ,�✓`�J�S� LEAD CERT NUMBER�V/¢T�' �D(� 3 3"�
YOUR STATE LICENSE ��ev'
AND CERTIFICATE OF ADDRESS: �B r% �%�GtSSo �/'lJs ,D� CITY fIQ STATE�ZIP✓nSI13
1NSURANCE pHONE �Jr�—sZ� �' /� / U FAX ��! - 3yy o yy�
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
■ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDlT10N ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ■ ROOF ❑ DRAIN TILE
O DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION Q� r��Q �
❑ MAINTENANCE/REPAIR ❑ REMODELING �C
DESCRIBE WORK BE1NG DONE: �� IQUd "jC
SIZE OF 1MPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFIN �� ❑ HOUSE ONLY BASEMENT REMODELING �UBMIT�
NUMBER OF SQUARES 0 HOUSE & GARAGE �. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
gjp�G FORNEW CONSTRUCTION INCLUDING t�ECKS,
❑ y�n � ADD1T10NS. & PORCHES SUBMIT:
Y ❑So�t 1. Site Plan/Surve showin the existi structures
❑ Aluminum O Trim Y B nB
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. EnergyCalculations
IN EXISTINC OPENINGS OYes 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 INSTALLED NUMBER OF WINDOWS
TOTAL
HLL PGG�,7 HIIL' DH�JGL Vl\ V HLUAIIVPI� 11�Il,LUL11Vli I I"Ir. (.VJl VN LAI�UK AIV� MAjI�.RIAL�:
(USiNG THE 1997 U.B.0 FEE SCHEDULE)
VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
OCCUPANCY TYPE
$ � See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ G $ $5.00 (State Licensed Residential Contractors)
$ $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 ( )
_$ 1 n'1, Make checks. payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT1L 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 1 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 a31 w r1 iich re ui •es review and approval of plans. `
SIGNATURE OF APPLICANT PR1NT NAME �I/�.°- Q�f'Gi` DATE ��ifJ `a�G�%
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEPARATE PERMIT5 ARE REQUiRED FOR PLUMBING, ELECTRiCAL AND MECHANICAL WORK