P - 45774BUlldlrig $UII,�IN(i Permit No.�. � ��� �
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Inspections RESIDENTIAL APPLICATION Re�ei�ed By: �
763-572-3604 CITY OF FRIDLEY Date �� � � � . °� � ��
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE '2 (� YOUR E-MAIL ADDRESS /� 'SG Q�W�'t-�iiLr'�o ��/�%Ctl . COM
SITE ADDRESS �Z�-b C/�-Pi ]a(� g T N�
THIS APPLICANT iS: ❑ OWNER �NTRACTOR
PROPERTY OWNER/ NAME: R� S�S
TENANT a��RESS: 5228 ,C,A-P_t�T�n�-- S T N� crTY �-t p ���{ sraTE �e�zlP �5��
PHONE: !% 3 - ,��I Z " � ZZ'L
CONTRACTOR NAME: �.l�1,k�Q.. 1?�dr�/nJ'���j ,
SUBMIT A COPY OF STATE LICENSE # !� �f'j�� LEAD CERT NUMBER �-_" p S�I /'� � 6'� v Sf S�z
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �Z� �% C=A�P ' R-D CITY �T- P�4VL- STATE►1�/.�IP � E�1 �
INSURANCE p!-IONE C - (-- Oqlv FAX (—Z I--C�Ll1%
PROPERTY TYPE �"SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTiON STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ,�ROOF ❑'DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�u1AINTENANCEIREPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: T�Q�2 O i� A-1'J� rF9I�6p F �� ��C� Pp(LCj-1 I�W g(p� ��� :�E �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT S�'r0 � M
ROOFING „�'fiOUSE ONLY ���'G'] �
NUMBER OF SQUARES _�_ ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT: '
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structwal members to be used
PROPOSED HEIGHT:
SIDING FORNEW 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 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 AR� BAS�ll ON VALUATION,INCLUDING THE COST ON' LABUR ANll MATERlALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ `7/~I ,� OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ �LZ_ $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 O Non Necessary O
Total Due $ '� 5_ 7 �i Make checks pavable 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 p rmit 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 rk ich r ires review and approval of p1an�N 9� n���
SIGNATURE OF APPLICANT PRINT NAME f` DATE C� �Z �/� �
PLEASE NOTE: SEPARATE PERNIITS `ARE REOUIRED FOR PLUMBING, ELECTRICAL AND MEeHAI�]ICAL WO1tK