P - 37248�3uilding � BUILDING I Permit No.:
Inspections RESIDENTIAL APPLICATION Recei�ecl sy: �`
763-572-3604 CITY OF FRIDLEY Da '�! �,
763-502-4977 FAX �� `�=�-��—��
EFFECTIVE 1-1-2011
DATE � l r YOUR E-MA1L ADDRESS 1 r F� /� k r ec l� e�-�er � C1�°'S � C,.,G i�.
SITE ADDRESS %l0� % iCTtitl/2 S fYZ��-T �c�
THIS APPLICANT IS: OWNER
PROPERTY OWNER/ NAME: �/� � ti'n� r N K
TENANT ADDRESS: �67 7 �iLTFfG�f,� ��r'eC7t /��CITY
PHONE; �O/a2 - a.�.� 9q3 =z-
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
i�ZFGG,��
�
STATE LICENSE # � � 7 LEAD CERT NUM
ADDRESS: ��(�� /✓�I�G���r'� f}7"<�t'� CITY
PHONR �iSl" ��� �31�d FAX //�S� �
�INGLE FAMILY W CONSTRUCTION
CONSTRUCTION
ADDITION GE/SHED
BASEMENT FINISH ROOF
DECK
SWIMMING POOL
SIZE
STORIES
WINDOWS
DRAIN TILE
OTHER
TYPE OF WORK: NEW HOME CONSTRUCTION ADDITION
MAINTENANCE/REPAIR REMODELING
DESCRIBE WORK BEING DONE: F�" � ��
SIZE OF IMPROVEMENT
ROOFING �j �}
NUMBER OF SQUARES T ��
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
Vinyl
Aluminum
Other
HOUSE ONLY
HOUSE & GARAGE
ATTACHED GARAGE
DETACHED GARAGE
_STATE�ZIP '�S .3�-
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't STATE/'�'i�ZIPJSO��i
E � J'Coo �
F1'
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUbING DECKS,
Soffit ADDTTIONS. & PORCHES SUBMIT:
Trim I. Site Plan/Survey showing the existing shuctures
Fascia and proposed project.
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 CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ %D, %O�_ C'.� nr�rTVSivrv TVDTi
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 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 payable to: City of Fridley 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 wor_ which re u' � view and approval of plans. /� .y
SIGNATURE OF APPLICANT A__���� PRINT NAME_ �CJIG�zZ�� DATE ��/ l/
APPROVAL INSPECTOR SIGNATU