P - 35760Building BUILDING Permit No.: � � �'-� (v�1
Inspections RESIDENTIAL APPLICATION Received By: ����,_
763-572-3604 CITY OF FRIDLEY vat :�, .
'763-502-4977 FAX �� —��� 1
EFFECTIVE 1-1-2011
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THIS APPLICANT IS: ❑ OWNER J��NTRACTOR
PROPERTY OWNER/ NAME: �/ O/�,I S'i" � OiSSG i"
TENA1v'r AnD�ss: 7 S b�j� � l� h �r � Ilk.,ci� ��.�1� sTa� �rn
rxorrE: `Z6{�i Sfo - 37. o.�
corr�acTOR N�: � Z�P ��n.od [ c ,r �on+�ra
SUBMIT A COPY OF STATE LICENSE # � � S EAD CERT NUMBER
YOUR STATE LICENSE --
AND CERTIFICATE OF ADDR�SS: � I � f� %,I1/ N(1�l CITY /�i n c�0 �/4l STATEL, NZIP�f,�d�
INSURANCE pHONE ` l.,�S �� FAX (�o N I ��
PROPERTY T'YPE SINGLE FAMILY/NEW CONSTRUCI'ION SIZE
❑ 'TWO FAMILY/NEW C�NSTRUCTION STORIES
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FIAIISH ,l�ROOF ❑ DRAIN TII,E
❑ DECK rj SIDING ❑ OTHER � � � � ��
D SWIMMINGPOOL _
TYPE OF WORK: ��IEW HOME CONSTRUCTION ❑ ADDI1'ION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE V10RK BEING DONE: TG� 1r ^ Gt i� G Od �
S1ZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ OiJSE ONLY
NUMBER OF SQUARES Zs a �HOUSE & GARAGE $ASEMENT REMODELING S��
I. Existing Floor Plan
,,f'r,ARAGE5 t ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of struct�ral members ta be used
PROPOSED HEIGHT:
� FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDIT�,ONS_ 8c POR�HES SUBMIT:
� Vinyl ❑Soffit i. Site Plan/Survey showing the existing structures
O Alwninum ❑ Trim
❑ Other ❑ Fascia � P�1�� 1�'oject.
2. Two scts of construction plans
WINDOWS 3. Energy Calculntions
IN EXISTING OPENINGS OYes 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 NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALiJATION. INCLUDING THE COST OF LABOR AND MATERiALS:
TOTAL JOB VALUA'
Pernut Fee
Plan Review
Fire Surcharge
Siu�charge
License Surcharge
SAC Cflarge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota( Dae
(USING THE 1997 U.B.� FEE SCHEDULE)
$ �► �� S See Back Page for Fee Schedule �
$ 65% of Building Pemut Fee
$ D� '.001 iimes the total job valuation
$ 3 .0005 x Permit Valuation Minimum $5.00
� 5 b $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee I�etem�ined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICA'IION FOR A PBRMIT-N�T 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 r 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 al w 'ch ires review and approval of plans. lI' (
SIGPiATURE OF APPLICANT PRIN'T NAME V t'C ���I �t �.I �� DATE ? ZlP
APPROVAL INSPECTOR SIGNA