P - 42176Buildin� , BUILDING permit Ivo:� : � ` �
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Inspections RESIDENTIAL APPLICATION Received By�Yc�
763-572-3604 CITY OF FRIDLEY D �° : r �
763-502-4977 FAX EFFECTIVE 1-1-2011 �� �
DATE_ .� — I S' I I YOUR E-MAIL ADDRESS YYt � QL t Lj"� v' C1 ��r� d e e+'�r�',� 5olu� ' s.
SITE ADDRESS S3 9 0 �'��` S'�' /� � �-yY i d � c-� M�
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: L i nc� Q I� ���'
TENANT �DRESS: S 3i O �`� �'j}' �j � CITY � ��- �G�( STATE N/ 1� ZIP �S�%� �
PHONE: �9(� ' S3 a2" �l� 3
CONTRACTOR xatva: a �-c� � ,rt
SUBMIT A COPY OF gTATE LICENSE # oZ0 LEAD CERT NUMBER (� FF� U��I � �'�
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: o� �{ O0 A! �at �-E c5 �-LiOi{- c�� f�'1�nrtecc� kS STA T� I � ZIP SSy ►(
INSURANCE PHONE ��D 3- ��v o�-- I'ZO FAX �I
PROPERTY TYPE n�1GL W CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED WS
❑ BASEMENT FIIdISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
0 SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDITION
O MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:___ trrl S'�d l� �✓� � kl 5�-i r,a o ve.n i na (►) t� m�or,+ ba-�.y ,�-� �p �`h- K W t�..�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
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:
IS DING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl pso�t ADDITIONS. & PORCHES SUBMIT:
0 Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed projeck
2. Two sets of construction plans
WINDOWS 3. Energy Calculadons
IN EXISTING OPEIVINGS es 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 NUIvIBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, 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
Total Due
THE 1997 U.B.0 FEE SCHEDULE)
$ �as..2r—
$
$ S,y-S"'�
$ � . 70�---
$ S. � a
$
$
$
$
$
See Back Page for Fee Schedule � q �, �' `
65% of Building Permit Fee /.t r-� r
.001 times the total job valuation S• y� " S• y t'
.0005 x Permit Valuation Minimum $5.00 �y
$5.00 (State Licensed Residential Contractors) ��• �a S'�
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks navable to: Citv of Fridlev Attac6 Stiuulation
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN'CIL 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 Conshuction Codes; that I understand this is not a
permit but only an application for a pe 't 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 w' ires review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME 1'v1e- t i 53s- f�t.l.��' +--� DATE � f S~ f(
APPROVAL INSPECTOR SIGNATU ,- . � v