P - 46602Building BUILDING Permit rio.�6
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY ���d'� U 0 2011
763-502-4977 FAX EFFEC� i-i-os
DATE /fJe rl. ', Z O/ I YOUR E-MAIL ADDRESS �OQ�(� Q/oh,n.2l� v. S't vc Ce�.; L � vv�
SITE ADDRESS /b /t�E, d6 wa v Fr: �/ ✓ r1n, S"S5/�3 �
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: L� ar'�l ; c�irna �
TENANT ADDRES� (� %1%G (,� G�i- u� a Ci1� �r � v!/� ✓ STaTEA�� Z� fS�Sf 3"�-
PHONE: %` � ° �" % I ' g � `� 01.
NAME:
CONTRACTOR ADDRESS: � 7OU ;�U�' �J ✓f. S U CTTY /✓I PL S STATE /�%I�LIP .��'y� 6
SUBMIT A COPY OF pHONE ��a -�aa —'�� d�1 FAX __ _ 6� c1 �% o� �� a 0 g�
YOUR STATE LICENSE STATE LICENSE # �e �3 �d �� EXP DATE .3' 3I � 2 OI a
PROPER'TY TYPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE 2M i a r
❑ TWO FAMILY/NEW CONSTRUCTION STORIES /
PERMIT TYPE � �DITTON ❑ GARAGE/SHED ❑ WINDOwS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN T'II,E
❑ DECK '�'SIDING st`�C� o ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDfTION
�°MAINTENANCE/REPAIIZ ❑ REMODELING
DESCRIBE WORK BEING DONE: �3r d � � r H /' i OL c'!�►"d cj�
SIZE OF INIPROVEMENT LENGTH Z Y� WIDTH HEIGHT � d sQ FT !
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �HOU3E & GARAGE
1. Existing Floor Plan
GARAGES � ATTA�HED GARAGE 2. Proposed floor plan
ROPOSED SIZE: ❑ DETACHED GARAGE 3. List of strucrival members to be used
ROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing siructtves
and proposed project.
"�Other S-�UC [ a ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL !'L�,L�,J AKL 1fAJL� L ViV VALUAl1V1V� liVl;LUll11Vl: ltl� C;Ua'1' UN' LA13UK A1Vll MA'l��:R1ALS:
(USING �HE 1997 UBC FEE SCI�EDULE)
TOTAL JOB VALUATION $�„3� �.�1 -°— 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
$ G� �,ZS See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ •(es .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ $5.00 (State Licensed Residential Contractors)
$ $1825 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$21=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ ,?j Make checks payable to: City 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 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
�ermit on site; that the work will be in accordance with the approved plan in the case of all work which requires review and approval of plans.
IGNATtIRE OF APPLICANT ��s-�-�%�� PRINT NAME T� o�is' D. Bea�n t Z�Zf`DA'I'E /I '%.�U,�
APPROVED BY
PLEASE NOTE: SEPARATE PERNIITS ARE REOUIRED FOR
DATE
ELECTRICAL AND MECHANICAL WORK