P - 42103Building $UILDING Permit No.
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY ��iz��Y
763-502-4977 FAX EFFECTIVE I-1-2011
DATE S� l 3 `- j 1 YOUR E-MAIL ADDRESS
SITE ADDRESS I��o f'I 1��- v r
THIS APPLICANT IS: ❑ OWNER f�CONTRACTOR
PROPERTY OWNER/ NqME: c �.,ti .� (e � Q w�- ��
TENANT qDDRESS: l S 6�/ � S�{ .L
CITY STATE ZIP
PHONE: %6 3 — �7 / 7 — � �l 3 (
CONTRACTOR NAME: S�- !7 GP-M-.g c o�mz. y�- r e- .-•oo� �e J i'.tiy
SUBMIT A COPY OF STATE LICENSE # 20 � 2! 2 G� LEAD CERT NUMBER �, I ��� Y �� �{ 2 Z6
YOUit STATE LICENSE
AND CERTIFICATE OF ADDRESS: 73G � �(to .�� e a r CITY �a .tis� �. . STATFi�� ZIP °i23�
INSURANCE pHONE %�S �' S�(o " f l 8' 3 FAX �7 6 3- y z/- c� o s t ss3 e 3
PROPERTY TYPE lg'SINGLE FAMILYMEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ��pITION ❑ GARAGE/SHED Q WINDOWS
❑ BASEMENT FINISH � ROOF ❑ DRAfN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTfON ❑ ADdITION
�'MAINTENANCElREPAIR Q REMODELING
DESCRIBE WORK BEING DONE: (' e t B o-�-
SIZE OF IMPROVEMENT LENGTN WiDi'H HEiGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES � D ❑ HOUSE & GARAGE I. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of svuctural members to be used
PROPOSED HEIGHT:
��G FOR NEW CONSTRUCTION fNCLUDiNG DECKS,
❑ Vinyl ❑Sof�it ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing swctures
and proposed project.
❑ Od�er ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHAI3GES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL r Er;� AKL liAaEll ViV VALUA l 1V1V, 11VC:LUllI1Vl� '1'H� C;U� 1' Ur' LAl3UK A1Vll MA'1'LKlALS:
[j�! ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $—`C�(� 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
��/
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,.f��
�i'Ii:��v
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 tirnes 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
Pee Determined by Engineering
Agreement necessary ( ) Non Necessary ( ) .
Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSBD
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 mit 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 al ��' equires review and approval of plans. r
SIGNATURE OF APPLICANT J� �� PRINT NAME S L.�..-�- �S. �' DATE s"1 3—� l
APPROVAL INSPECTOR SIGNATURE