P - 45502Building BUILDIl�G Pe�it Ivo.: ���
Inspections RESIDENTIAL AP�LICATION Received By: ��'
763-572-3604 CITY OF FRIDLEY D� °
763-502-4977 FAX �� ������
EFFECTIVE 1-I-2011
DATE /�%l l ao i � YOUR �MAIL ADDRESS DG.%� � / O�_l �� S�, C� �^n
SITE ADDR�SS _ J� �i7d Ga �' S' � �-.C- !'"l' �/T , i%�! � S � y.� �
'fHIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNERI NAM�: e N ' ��
TENANT �DRESS: S�%L� %� S�. �U.C- CITY P STATE �%�L1P SS .3�
PHONE: �%(03 ` v� 3 �I ' (� 'rj / s
CONTRACTOR NAtvtE: �✓ / S Sd �. S,� a�- �� ` c% ���✓S ,�� Cr
SUBMIT A COPY OF STATE LICENSE # r� Ii.3 l%.5.�l� � LEAD CERT NUMBER� I 3� g I S'v
YOUR STATE LICENSE
AND CERTIFICATE OF ADDI2ESS: y$/�_, f b S� �,�. f1/.c CITY L�:lG�C �� STATE M6✓ZIP S�/
INSURANCE PHONE � �v •� — FAX
PROPERTY TYPE O�ISINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDIT'ION O GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FIAiISH �ROOF ❑ DRAIN TILE
❑ DECK C7SIDING ❑ OTHER
❑ SWIMMING POOL
T'YPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
{�MAINTENANCE,lREPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: e' Ud t,�, �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT 3 FT
ROQFING r� r�2iHOUSE O2�iLY
NUMBER OF SQUAItES o� 7 y ❑ HOUSE 8c GARAGE BASEMENT REMODELING SUBMIT:
1. Ea�sting Floor Plan
GARAGFi,� ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
�IDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl OSoffit ADDITIONS.,,�& PORCHES St�BMIT:
❑ Aluminum � Trim 1. Site P1an/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction pians
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINIGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED I3UMBER OF WINDOWS
ALL N'L�'1:� AKL�' KA`�LD UN VALUA'l7UN, llVC:LUllIiVC; "LHI: C:VS"1' UN LAKUH A1Vll MA'1'L� KIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
� �� Gl N OCCUPANCY TYPE
$ 'j, � See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $S.OQ
$ $5.00 (State Licensed Residential Coniractors)
$ $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 ( )
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge 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
a roved lan in the case of a11 rk which uires 'e and a mval of 1� A �
SPGNATUREOFAPPLICANT ���� ��_ rp�xnlvtEpi/���:,, S_ ff,�,s'c•, nn� � �� .�t/
APPROVAL INSPECTOR SIGNA�[J�E
PI.EASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING. ELECTRICAL AND MECHANICAL WORK