P - 48274Building BUILI�ING Permit No.: � 6 ����(�'
Inspections RESIDENTIAL APPLICATION Received By: ��
763-572-3604 CITY OF FRIDLEY Date xec'ct: 1 r�2 I— i l
763-502-4977 FAX EFFECTIVE 11-2011
DATE I `Z. YOUR E-MAIL ADDRESS __ K�i�'1C�ZAVZ ��hpp t COYv�
SITE ADDRESS bO� LI � RVE. N�E \" Y �c�► IV�1LJ rJS� 32--
THIS APFLICANT IS: �, y�OWNER �CONTRACTOR
PROPERTY OWNER/ sNAME: �� �}�.�� �"ptM pt
TENANT pDDRESS: (�O$ S�3'r� �1vc. N� CITY �i�1L���1�1 STATEM� ZIP 55 3z
PHONE: �o1Z' -rj� S �j�22
CONTRACTOR � :
SUBMIT A COPY OF
YOUR STATE LICENSE ST � LICENSE # LEAD CERT NUMBER EXP:
AND CERTIFICATE OF DR�'$S: CITY STATE ZIP
INSURANCE PHONE� FAX
PROPERTY TYPE O SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE O ADDIT'ION O GARAGE/SHED WINDOWS
❑ BASEMENT FINISH ❑ ROOF � DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
� ❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � ��'�rS lrtJ IY�Git�.J
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY $ASEMENT RFMODEr.iNG SUBMIT•
NUMBER OF SQUARES ❑ HOUSE & GARAGE �. Existing Floor Plan
�ARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE , 3. List of structural members to be used
PROPOSED HEIGHT:
ING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS & PORCHES S BMIT•
O Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO �• Site Plan/Survey showing the existing structures
❑ Other p g��a and proposed project.
2. Two sets of construction plans
W���'�'S ' 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPEI�IING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS•
'OTAL JOB VALUA'
Permit Fee
Plan Review
Fire Suroharge
Suroharge
License Surchaxge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
4USING THE 1997 U.B.0 FEE SCHEDULE) �
$ "
$ SO
$
$
$
$
$
$
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 pa_yabte to: Citv of Fridlev Attac
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 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 s without a permit on site; that the work will be in accordance with the
approved plan in the case of al tk w`ti� re review and provai of a
SIGNATURE OF APPLICANT K PRINT�.I ��� (�r .�r1''''►`V DATE 1` 2� a 1(
APPROVAL INSPECTOR SIGNA �1T � � _ _ �.� ..T-
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