P - 3963813���s'
Building BUILDING Pe�nit No � �--� 7�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'a:
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE ( YOUR E-MAIL ADDRESS /V/�%
SITE ADDRESS S��U L7 �— �7' N�-
THIS APPLICANT IS: ❑ OWNER j�CONTRACTOR
PROPERTY OWNER/ NAME: /%�j?i�;�c.�,f �¢,L!'�
TENANT ADDRESS: �� ��'�°� cS� M� CITY 'r�CfGC.t./ STAT�I_ .l ZIP��
PHONE: %1e,7�...5%%" ��Ilss %
CONTRACTOR NAME: ` t1CSG
SUBMIT A COPY OF STATE LICENSE # r�j l�v:3�J c1''3 LEAD CERT NUMBER%.,��3 �' f
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS:��t� %.Ull� �.7/iY ��; S7� I��� CITY<<'l STAT�IY_ 1� ZIP 5S% � I
INSURANCE PHONE ID;S /-- ��S "' L7l Q � FAX .%•— S° �
PROPERTY TYPE j�f siNGt,E FaNttLY sizE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERI�IIT TYPE ��DDITION LJ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
"j� MAINTENANCE(REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: 1 ''�' � '
SIZE OF IMPROVEMENT LENGTH WID HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT
NUMBER OF SQUARES ❑ HOUSE & GARAGE
1. 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,
5IDING ADDITIONS_ & PORCHES 5UBMIT:
❑ Vinyl ❑Soffit
❑ Aluminum ❑�r�m 1. Site Plan/Survey showing the existing stmctures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �IYes ❑No 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
ALL FEES ARE BASLD UN VALUA'1'IU1V, 1NCLUllIiVC:'lHL�' CU,1 UN LAIiVKA1VU 1V1AlEK1AL5:
(USING T�IE,�, �1,9�9y7 U\.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ ( OX�J�J _ 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
$ ' J,�. �;,� See Back P'age for Fee Schedule
$ 65% of Buiiding Permit Fee
$ � .001 times the total job valuation
$ 9 .0005 x Permit Valuation Minimum $5.00
$ S; Q $5.00 (State Licensed Residential Contractors)
$ � $2230 per SAC Unit (Plans to MWCC far determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ greement necessary ( ) Non Necessary ( )
$ , _ Make checks payable to: City of Fridley 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 ardinanc s nd codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio r p d 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 iew and approval of p� '% // ��� �a� l��
SIGNATURE OF APPLICANT PRINT NAME %�'� /5� /C ��DaTE �
APPROVAL INSPECTOR SIG RE
ARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHAl�TICAL WORK