P - 35259f L' +{'�' � i
Building BUILDING Permitivo.: '2�� -{�J�3
Inspections RESIDENTIAL APPLICATION Received By: 1� U�;�
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX �� �� �� �
EFFECTNE 1-1-2011
DATE /� 2 f" �� _ YOUR E-MAIL ADDRESS
SITE ADDRESS �,S_'T � ��� Sf"
THIS APPLICANT IS: O OWNER �CONTRACTOK
PROPERTY OWNER/ NAME: /1r �'�% K r
TENANT ADDRESS: � 7� �� Sr CITY — _STATE'!'� ZIP S�f'�/3
PHONE: DELING, INC,
CONTRACTOR NAME: Tl �O C@i1�dl venue
SUBMIT A COPY OF STATE L[CENSE # Spring La e r AD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
1NSURANCE pHONE C' FAX
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
� BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRTBE WORK BEING DONE: k�"C� d"' G
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING Z�. ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ 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:
FOR NEW CONSTRUCTION INCLUDING DECKS,
IDIN ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soff"it 1. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim and proposed project.
❑ Other ❑ Fascia 2, Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOW S 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
ALL NL�'L� 5 AKN: BA�L�'ll U1V VALUAIIUIV, 11Vl:LUll11VCi 1H� C,(JJI VN LAtfVK A1rU lYIAIL� KIALJ:
_(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park 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 determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks navable to: Ciri of Fridlev 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 and co s of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f a p it and work is not to start without a p rmit on si ; that the work will be in accordance with the
approved plan in the case of a k ' w and approval of pla . �1 -..�,) —7
SIGNATURE OF APPLICANT PRINT NAME N� `�T� v DATE /` 2�— �/
APPROVAL INSPECTOR SIGN TU