P - 45134Building BUILDING Permit No.: `�� I �'�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY FOF�FRIIDLEY Dat���d��%� 2� �011
763-502-4977 FAX
DATE �✓-� I"- �� YOUR E-MAIL ADDRESS V� C Ic �� V 1 C lC ►n e �' �ll �C �� S . CO 1'Y�.
SITE ADDRESS 7 Li ��r �� CO Y�% �� 1 N C_
THIS APPLICANT IS: ❑ OWNER �'CONTRACTOR
PROPERTY OWNER/
TENAIVT
�
ADDRESS
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Vsr� � cvw n �
PHONE: �% i�v 3 — % � 3 � a ! ? �
=CITY � l�C I YJ � C'�/ STATE I%�) IvZIP�Z
CONTRACTOR N,��: �nl C Ic bv (�. ?2 (� l� l� V'J L.-7'1 S -� � C •
SUBMIT A COPY OF STATE LICENSE #� C- � O 3�[ Y C� LEAD CERT NUMBER
YOUR STATE LICENSE N-
AND CERTIFICATE OF ADDRESS: �n %"3 U I-1 W y G� S��" �� v� CITY � I Y� L1 STATE�'I� "GIP��j
INSURANCE PHONE _ _� � �� � / y"' �l Fl% / FAX `I t� � �' .g'�% y'— �% � � �
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE 0�DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �'1F�OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �C � 2C�
SIZ6 OF [MPROVEMENT
ROOFING �/'�
NUMBER OF SQUARES _�L �
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
LENGTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
O ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WtNDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WMDOW TO BE INSTALLED NUMBER OF \
f:l�l[el�Yl
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AN,D MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totat Due
$ �r�1�5, 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 ( )
$ Matce checks aavable to: Citv of Fridlev 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 al wor whi h re u'res rev�e and approval of plans. ^�
SIGNATURE OF APPLICANT �i��:�J�T� Ll� PRINT NAME l� I C IL � I C�C Wi�L'DATE I ri �G -I ""-� I I