P - 39612Building BUILDING Perrnit No.: `� �'�' t� -��4
Inspections RESIDENTIAL APPLICATION Re�ei�ea By: :�,� �,
763-572-3604 CITY OF FRIDLEY D��°�►:UG 2��
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE S-��^ � I YOUR E-MA1L ADDRESS CCti�J�GL� al KP� }�o �y�Q,���L IVn �•
SITE ADDRESS `J� % ! 8 - � �0:0 Ca rf� ��, tii�: ,
THIS APPLICANT IS: ❑ OWNER �`CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF IMPROVEMENT
NAME:
1 t�,v�
ADDRESS: S�P C�'" ��' ZO C9�� CITY �21r�LQt� STATEm�N ZIP �5`� � Z�
PHONE: ip � oi -�. �'iO� Z 2�C%
Nan�E: L� e �!�
STATE L.ICENSE #
ADDRESS: � 3�c 3 I �l (�.2�.�?
PHONE � L 2- � �L(T' 2 2 0 C�
LEAD CERT NUMBERi
��� CITY 6'1 PrM `A�� STATE M'�IP S�D
FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE i l l7U S C�
�'I'WO FAMILYMEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
[7 BASEMENT FINISH �ROOF ❑ DRAIN TILE
C] DECK I� SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
AINTENANCE/REPAIR ❑ REMODELING
,. K eL� !�[P_ �U� 'C"S � .^� .11.P. c �9uX i3 `l ► i� �Nn '1! ) N c�j ()�
ROOFING ���
NUMBER OF SQUARES _�_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SI ING ��` rL � 0 e''�:,
V inyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPBNING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
`�DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF
WIDTH
FT
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�
1. Site Plan/Survey showing the existing structures
and proposed proiect.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WiNDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
( S NG 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
I Park Fee
� Sewer Main Charge
Total Due
$
$
$ �a
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.00I 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 uavable to: Citv 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 permit on site; that the work will be in accordance with the
approved plan in the case of all < which re ir review and approval of plar�� �� `, n Q a4^ ``
SIGNATURE OF APPLICANT PRINT NAME � Q�N y� �"{►{�921lDATE 0
APPROVAL INSPECTOR SIGNATURE �