P - 48343Buiiding BUILDING Permit No.•� " � �
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 �
763-502-4977 FAX CITY OF FRIDLEY vate Re�'d:
EFFECT[VE t-1-2011
DATE lo "i3' (I YOURE-MAILAbDRESS rOOFQ1QL�Or . (•C
SITE ADDRESS �r R 9 �" S�ftt '�' ��
THIS APPLICANT IS: ❑ OWNER OQCONTRACTOR
PROPERTY OWNER/ NAME: v
TENANT ADDRESS:�(� �7 S� S� /� r cr� �� �� y STATF�f.� �fIZiP 5�.3
PHONE: S� SI � O / !�
CONTRACTOR NAME:�oc F ���/' �rti
SUBMIT A COPY OF STATE LICENSE # ,� o� 39 y� U LEAD CERT NUMBER
YOUR STATE LICENSE n
AND CERTTFICATE OF ADDRESS: a � 3 � 1 �n J�n% �.► Z pad� �( CiTY i 5 STATE�_ZIP S %
INSiJRANCE Pxox� 7�3 -�/y� - b 3/y FAX 7�r _ 9
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/l�IFW CONSTRUCTION STORiES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH 1�ROOF ❑ DRAiN TILE
❑ DECK ❑ SIDING � OTHER
❑ SWTMMiNG POOL
TYPE OF WORK: � NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ��� 'F � �� _
SIZE OF IMPROVEMENT LENGTH WiDTH HEIGHT SQ FT
ROOFING HOUSF. ONLY
NLJMBER OF SQUARES � �,E BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: �,'DETACHED GARAGE 3. List of struchual members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTTON TNCLUDR�IG DECKS,
❑ Vinyl ❑Soffit ADDITIONS, & PORCHES SUBMIT:
O Aluminum ❑ Trim 1. Site Plan/Survey showing the existing struchues
❑ Other ❑ Fascia and proposed project.
2. Two sets of coustruction plans
WINDpwg 3. Ener�,ry Calculations
IN EXISTING OPENINGS OYes ❑No LOCATTON OF WTNDOWS FOR WiNDOWS — PROVIDE U-VALLTE AND
OR FOR NEW OPENINGS-DESCRIBE SiZE OF MANUFAC"['IJRE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WiNDOWS
ALL FEES ARE BASED ON VALUATIOIY, INCLUllING 7'HE CUS'1' UP' LASUK ANll MA'l �1tlAL,:
([TSING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ . OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �.
$
$ , U�
$ � � -
$
$
$
$
$
$ ic�
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minunum $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: Citv of Fridlev Attach
THIS IS AN APPLICATION F�R 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 ordinanc d o es of the City�6f Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio fo pe 't w is not to start without a pernut on site; that the work will be in accordance with the
approved plan in the case of al w c equires review and approval of plans. `/ �
SIGNATURE OF APPLICANT � PRiNT NAME DATE� �` T�` �
APPROVAL INSPECTOR SIGNA
PLEASE NOTE: SEP TE $ ITS A REOLTIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK
� �a�- � l / D/ od� % �''fy o f ������