P - 45756Building BUILDING Pe��t No.: �' � �f �
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY vate R� ��`�� '��'
763-5�2-4977 FAX EFFECTIVE 1-1-2011
DATE �" Li3 " � � YOUR E-MAIL ADDRESS �/�7"� l��% �-� It�C7 �%ll�"S �'F-�f`' W�L� �(� M
SITE ADDRESS � FC C3IL1I° �ZC,7 ��iZ. �
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY OWNER/ NAME: R'I�� �-- �2-�-FYL�/J
TENANT ADDRESS: �O�OC7 B�UC�K iJ.,�P�t,3 /��- CITY y���+-4A-�- � STATE
y �ZIP �� 3
PHONE: �I(�D �'� % I- 7l C� I
CONTRACTOR N�:�4i3� r�-�' A�� /� �'7�� 7� �-�D�`Z�� ��� �
SUBMIT A COPY OF STATE LICENSE #�0.� � I�S LEAD CERT NUMBER �,�rrraYo9 '� I
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: f� L� MA3."7S� S� �A.� LZ-� CITY�A�I� STATFj�9�IZIP�
INSURANCE pH '�J�l '�J — � � �� Z� FAX �I fo 3 "L}'r"'( "'� � ZaJ
PROPERTY TYPE SINGLE FAMILY/PiEi�V(�APi9�fON SIZE
❑ TWO FAMILY/NEW CONSTRUCT[ON STORIES
PERMIT TYPE ❑ ADDITION ❑�T n1zAGFlsx� ❑ w�NDOws
❑ BASEMENT FINISH jd ROOF ❑ DRAIN TILE
� DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ HOME CONSTRUCT'ION ❑ ADDITION
Jl�INTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENI' REMODELING SUBMIT:
NUMBER OF SQUARES Z� ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural membeas to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site PIanlSurvey showing the e�tisting structures
❑ Other ❑ Fascia � P�� P�j�.
2. Two sets of construction pla�s
WINDOWS 3. Energy CalcWations
IN EXISTING OPENINGS �Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON W7NDOW.
OPENING CHANGES &c
TYPE OF WINDOW TO BE INSTALLED NIJMBER OF WINDOWS
Ai,i. r�:�a Ax� n.���L V1� vn1.UAllulr, livl;LUUIiVIT lH�: L'V�"1 Ur' LABUK APIll MA"1'�:KIAL�:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ � OCCIJPANCY TYPE
Permit Fee
Plan Review
Fire Surchazge
Swcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Comrol
Pazk Fee
Sewer Main Charge
Total Due
$ YI �'� , �.'�
$
$
$
$ S d
$
$
$
$
$
$ `
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 Residenrial Contractors)
$2230 per SAC Unit (Plans to MWCC for detetminarion)
ft+6ft= ftx$25=$
$450 Conservation Ptan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable to: City of Fridlev Attach
THIS IS AN APPL[CATION FOR A PERMIT-NOT VALID LJNTIL 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 ' of Fridley and with the Minnesota Construcrion Codes; that I undeistac►d this is not a
permit but only an applica ' for permit and w is not to start without a pennit on site; that the work will be in accordance with the
approved plan in the case o al w �c ui� eview and approvat of lans.
SIGNATURE OF APPLICANT - PRIN'C NAME�� �i t�� DATE �0�� I��
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEPARATE PERMTTS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK
I.1:.