P - 46273Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION �ei�ect By�.
763-572-3604 CITY OF FRIDLEY �-�-�`-� �
763-502-4977 FAX EFFECTNE 1-1-2011 �� l �/ � ; �
DATE�-� -flt( `l — I I YOUR E-MAIL ADDRESS
SITE ADDRESS S�OC� � c� X,).1�
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY OWNER/ NAME: ��['�JQ�,� f��C-1, f�C) .
TENANT pDDRESS: ��� ,�� c�iU.2' C►TY �/�(1y STATE�I IP ,�"'�� .
PHONE: �{e'� —,53Y /cJc�`+�
CONTRACTOR NAME: �c/L�� �� Cc3c) ,
SUBMIT A COPY OF STATE LICENSE #�p �/5��� LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �� CJeCAs�z2.S�lG' A�I.C� CITY�Q[�STATE�/I7 P�
INSURANCE PHONE FAX �
PROPERTY TYPE �hIGLE FAMILYMEW CONSTRUCTION SIZE
❑�7'WO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK SIDWG ❑ OTHER
� SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDITION
TENANCE/REPAIR C] REMODELING
DESCRIBE WORK BEING DONE: �'r_ � ��'%�sC./ �/.{7t.1i4C� - �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
R O NG .� ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES � ❑ HOUSE & GARAGE
I. 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,
ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl OSoffit L Site Plan/Survey showing the existing shucpues
❑ Aluminum ❑ Trim and proposed project.
❑ Other ❑ Fascia
2. Two sets of conswction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS DYes ❑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 BASED ON VALUATION,INCLUDING THE COST OF LABOR AND MATERIALS:
(USING 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
$ �j'j. (�7 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 ( )
$ A I Make checks navable to: Citv of Fridlev Attac
THIS IS AN APPLICATTON FOR A PERMIT-NOT VALID LINTIL 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 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 all�j or w e'•e review and approval of plans.
SIGNATURE OF APPLICANT Q` � PR1NT NAME ,�.fTiC,� �'�,f%f%ii� DATE Crr�iid �/�
APPROVAL MSPECTOR SIGNAT
��