P - 45304Building
Inspections
763-572-3604
763-502-4977 FAX
DATE �� �Z- 1�
SITE ADDRESS S G � Z^ S�' �
BUILDING
Permit No.
RESIDENTIAL APPLICATION Received By: r Y
CITY OF FRIDLEY ���e��:L � � ' Q��
EFFECTIVE i-I-2011
YOUR E-MAIL ADDRESS C/'�T��� KQN �` Q CDMC0.S� �N .
� s. NF.
THIS APPLICANT IS: i$(OWNER ❑CONTRACTOR
PROPERTY OW1vER/ Na�E: e�,N�.�h Rf3`c N f} �PZ
TENANT qDDRESS: � 3�0 3 � PtW2e�¢. S''E' N£ ,
CITY AM LAKrZ.
PHONE: t� i2 "Q �O� Z2.,8O
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TY.PE OF WORK:
STATE LICENSE
" L�e,�,¢,-t+, K • t'1�
_ LEAD CERT NUMBER
ADDRESS: CITY
PHONE FAX
C���..�AI�Q� Y/NEW CONSTRUCT]ON 3IZE
`TWO FAMILY,'NEW CONSTRUCTION STORIES Q�/Q sTOR�C
❑ ADDITION ❑ GARAGE/SHED � WINDOW3
❑ BASEMENT FINISH �( ROOF ❑ DRAIN TILE
❑ DECK � SID]NG ❑ OTHER
❑ SWIMM[NG POOL
O NEW HOME CONSTRUCT]ON ❑ ADDITfON
�S;MA]NTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
C�So
ROOFING f`�,
NUMBER OF SQUARES I O dN
GARAGES ��.
PROPOSED SIZE:
PROPOSED HEIGHT: ,�.
SIDING
Vinyl
❑ Aluminum ^i
Q Other �
WINDOWS
IN EXISTING OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRBE SIZE OF
OPENING CHANGES &
ATE (h� Z1P �� � 3 2.
ATE ZIP
On7 Tqraa�,,�' {2,�O�a�r olAa.A�.¢C.� S'1G�►NS H7t�1�, b`/1'rv►Q„ "ik/�Q �
GTH WIDTH HEIGHT SO FT
Q HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
�DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT
l. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction pians
3. Energy Calculations
fiOtt W[NDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
SING THE 1997 U.B.0 FEE SCHEDULE)
COTAL 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
Total Due
$ '�"�]�;� See $ack Page for Fee Schedule
$ 65% of Building Permit Fee
$ 1� .001 times the total job valuation
$ .0005 x Permit Valuation Minim�m $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 payable to: City of Fridiey Attach
THIS IS AN APPLICATION FQR 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 tY�e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application or a permit and work is not to start without a permit on site; that the work wilt be in accordance with the
approved plan in the case of work w1�i• re � ire review and approval of plans. "�� n }�('� r( - 13- ! 1
SIGNATURE OF APPLICANT krJ�„�2,�t'�-- � PRINT NAME K�.viv�h� 1�, ��I%1 �"M(G'i, DATE
APPROVAL INSPECTOR SIGNATUR