B - 48423Building BUILDING Perinit rio.: 26�2�
I�spe�tions RESIDENTIAL APPLICATION Received sy��'
763-572-3604 CITY OF FRIDLEY Dat�l�a.F ��� ���
763-502-4977 FAX EFPECTIVE t-1-2012
DATE�,.� YOUR�-MAILADDRESS�.r/Spvz��!% `'�'x� G' �n� - -
Sr� a�nRESS ���� � �' y l -� �����
THIS APPLICANT IS: ❑ OWNBR LRC�NTRACTOR
PROPER'['Y OWNER/ Np�: S'� �j2�,�iyy�CL
TENANT �Di]RESS:� �G's /%"%�PZ%� _._CITX��, ��y STAT��LI���,�
P1iONE: v /
CONTRACTOR NAIv1E:� � ._ ` ..� -�J` �'�S 1 %� —
SLIBMIT A COPY OF STATF. LICENSE #�7� , LEAD CERT NUMBEB`��T3O.3D.� l�' Xp� 5����
YOUR STATE LICENSE
AND CERTIFICATE OF ADARESS: ` O ° °� c�7 �1/l> � CITY��z'° /� STATF�%�ZIPS�
INSURANCE PHONE %� c /• ��> F� � � /
�ROPERTY TYPE ❑ �11��T F Fe�Y/NEW CONSTRL'CTION SIZE
� TWO fAMILY/NEW CONSTRUCTION STORIES�_,__
PERNIIT TYPE ❑ ADDITION ❑ GARAGFJSHED INDOWS
C3 BASEMENTFINISEi ❑ ROOP ❑ DRAIN T1LE
❑ DEC1C ❑ SIDING ❑ OTHER
� SWIMMING POOL
TYP� OF WORK: ❑ NT}W HOME CONS'CRUCTION 0 ADDITION
p�AINTSNANCE/REPAIR ❑ R�MODELING
BESCRIBE WORK BL�ING DONE ��f' /l Cr%/'7 G�Gt/�.� 'f �" L�� �°-S'
r
SIZE OF IMPROVEMENT LENGTFi WIbT _ H.EIGHT. S FP
RbOFTNC ❑ HOUS� ONLY BASE ' T REMOAELING SU IT:
NiiA�ER OF SQUAR�S 0 HOUSE. & GARAGE 1. Existiny Floor Plan
CARAGES ❑ ATTACHED GAR AGE 2. Proposcd floor plau
PROPOSED SIZE: ❑ DBTACHED GARAGF 3. List of structural members to bc used
PROPOSED HE[GHT:
— f'UR 1V8W CONSTRUCTFON INCLUDING DECKS,
SIDING ADDITIONB. & PORCHES SU$MIT:
❑ Vinyl ❑Sof�'it SIDIA'G/SOFFTPlFASCIA 1. Site Plai�/Survcy showiug fhe existing structures
❑ Atumimun Cl Trim REMOVED? C] YES ❑ NO and praposed project,
❑ Other __ ❑ Fascia 2. 1'wo sets of consfmclion plans
WINDOWS �/ 3. �nergy Calculations �
IN EXISTING OPENINGS 117Yes ❑No LOCATION OF WINDOWS F'OR WIlVDOWS — PROVIDE U-VA[.UE AND
Oli FQR NEW OPENINGS-DESCRIBE SIZE OP �% L..'�p�rl ^l w� Irt 11.}22.�_.� MANUCACTURE STICKER ON WINDOW.
OPENIIVG CH.ANGES &
TYPE OF WINDOW TO BE ]NSTALLE TIi3MBER OF WIIVDOWS
A i i�TTC ARF. RARF.1) /1N VAT,iTATInN_ INC_Y.i1DING THE COST OF LASOR AND MATEftIAL5:
'OTAL JOB VALUATION $
Pennit Fee
Plan Review
Fiace Surcharge_
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
{USING THE 1997 U.B.0 FEE SCHEDULE)
, � ,� OCCUPANCY TYPE
$ ?� 3. See Back Page for Fee Schedule
� - ��"65% of Building Permit Fee" " '
$ .001 times the tolal job valuation
$ � .0005 x Permit Valuation Minimum or .50
$ $5.00 (State I,icensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25—$
$ $450 Conservation Plan lteview
$ Fee Determined by Bngineering
� Agreement necessary ( ) Non Necessary ( )
� 1�.,. �1 ( Make checks qayable to: City of Fridley Attach
THIS 1S AN APPLICATiON FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pennit and I acknowledge lhat the information above is compiete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Cocies; tl�at I understand this is not a
pennit but only an application for a permit and work is not to start without a peimit on site; that #he work will be in accordance with t�e
approved plan in the case of 1 work whi h req "res review and approval of plans. /�
SIGNATURE OP APPLIC�k � A�/' ����Q�—�-1 _P€tINT I�AME�_y�ICtiL ���56.1��p�T��.-,� �1.1��.
APPROVAL INSPECTUR �TGN TiJRE
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