P - 42221Building BUILDING Permit No.:��"' ' � i'�
, '�r � � � }
Inspections RESIDENTIAL APPLICATION Received By: �'��
763-572-3604 C�TY OF FRIDLEY Dat :f—����'�
763-502-4977 FAX �� �
EFFECTIVE 7-1-2010
DATE O` J 1 U YOUR E-MAIL ADDRESS 1 1 1� C�� l l� l�i I 1� C� i� St� u CT 1 Un - C Q
SITE ADDRESS �� O ��`1 � AV e- N�
THIS APPLICANT IS: ❑ OWNER ,�CONTRACTOR
PROPERTY OWNER/ NAME: RO e'� V�.� O
TENANT pDDRESS: y I.D I�J- f�V N� CITY �R-1 ILI� STATEi"IN ZIP SS Z
PHONE:� �0 3- LD � 1 I�'i 1 e�i �
CONTRACTOR NAME: O '� G� U � C�
SUBMIT A COPY OF STATE LICENSE # o�O/� i-I �� 'rJO EXP DATE
YOUR STATE LICENSE /
AND CERTIFICATE OF ADDRESS: � q�J o� UY1j �/�iZ.S f _�v� n� � CITY t' _STATE�ZIP c5, Sc{3�
INSURANCE PHONE� — I FAX �� � � I
PROPERTY TYPE B`SSIIVGLE FAMILY/NEW CONSTRUCTION SIZE S�
❑ TWO FAMILY/NEW CONSTRUCTION STORIES�_
PERMIT TYPE O ADDITION O GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �J ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING � OTHER
O SWIMMING POOL
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCEJREPAIR �REMODELING
DESCRIBE WORK BEIMG DONE: T�GI � p FF c�r�d Re Qod � 1 S Q D�(�Od � W i t'h ���„C /� ti'°���+� R� ° F
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ItOOFING �lFE�OUSE ONLY BASEMEN'�REMOQELING SUBMIT:
NUMBER OF SQUARES O 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,
❑S�Vin�yl OSoffit ADDITIONS. & PORCHES SiJBMIT:
❑ Atuminum O Trim 1• Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two seu of construction plans
WINDOWS 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.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
Ai.i. FF.F.S ARF. RASF.D n11T VQLi)ATION. INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUA'
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
(USING THE 1
$
$
$
$
$
$
$
$ � , .f
FEE SCHEDULE)
OCCUPANCY
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)
$2100 per SAC Unit (Plans to MWCC fordetermination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: City of Fridley Attach
THIS [S 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 permit on site; that the work wi(1 be in accordance with the
approved plan in the case of all work whi h re u•es review and approval of plans. `` (�r^��� p
SIGNATURE OF APPLICANT �•M(�,(�X �t���� PRINT NAME ��G 2.��C _�C 011"I��Q!(1 DATE o I��1(i�
APPROVAL INSPECTOR SIGNATURE
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