P - 42828Building BUILDING Permit No.: —f� D
Inspections RESIDENTIAL APPLICATION Received By: ` '
763-572-3604
763-502-4977 FAX CITY OF FRIDLEY Date Rec'd:
EFFECTIVE 1-1-2011
DATE it� -11-2�i 1 YOUR E-MAIL ADDRESS
SITE ADDRESS �U�1'-1 �.�1f�1(,�`(� d7C�i
THIS APPLICANT IS: ❑ OWNER I�ONTRACTOR
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PROPERTY OWNER/ NAME: �' t�l.._ (�.���'
TENANT ,�DRESS:I.C���l� ��)(l('lr'7C�_ �]Q_ CITY_ 1r1� STATE'C`(���ZIP �cJt-��
PHONE',,]�t?'3 �c��"l�," :j,�~I�
CONTRACTOR NA�: � �
SUBMIT A COPY OF STATE LICENSE # C��1UJt%
LEAD CERT NUMBER — � �
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS:�J`'�C� r{� (�t^_ N � CITY�(�� CtG� . STATE�(hN ZIP `` ��
INSURANCE PHONE � � � �S FAX
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
/❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DITION ❑ Ga�GEis�D ❑ wlrmows
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING `�OTHER
❑ SWIMMING POOL /
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCElREPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: C�QIGIQ.- J'C'l'�1' t� -"c(�j('J��l.,
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED Gt1RAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPEI�IING5 ❑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 N'L+'L�'� AKL�' IfA�L�'ll V1V VALUA'1'lU1V,11V(:LUllllV(� 1'Hl; (:U�T VI+' LA13UK A1Vll MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�S� � OCCUPANCY TYPE
Permit Fee $ ,5 g� See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ , .001 times the total job valuation
Surcharge $ ,% J" .0005 x Permit Valuation Minimum $5.00
License Surcharge $ 5 o DQ� $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary-( ) Non Necessary ()
Total Due $ /� • n,� Make checks uavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID iJNTIL 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 Consh-uction Codes; that I understand this is not a
permit but only an app ' io for a permit and is not to start without a permit on site; that the work will be in accordance with the
approved plan in the c f al fork w i requ' •e ev w and a roval of pla
SIGNATURE OF APPLIC ' �� T NAME ATE "'�
APPROVAL INSPECTOR ll�f v
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