P - 35446Building BUILDING Pe�it rto.:ZOI �
Inspections RESIDENTIAL APPLICATION Received By: '�Y
763-572-3604 CITY OF FRIDLEY j
763-502-4977 FAX ��;�c���
EFFECTIVE 1-1-2011
DATE /�'t � �C,�i L aZ O, oZ O l I YOUR E-MAIL ADDRESS
SITE ADDRESS _�'� t/'� �J a.l-�-K..a L l� J t rt,%� � j d j. rr �( N�t 11� �Sy'3�
THIS APPLICANT IS: �.OWNER OCONTRACTOR
PROPERTY OWNER/ NAME: (�'l t4.,c.i �4 le. � o s R..r x r►�... I•_
TENANT ADDRESS: �q �L i G� t e,!-�w4 / i�W A.��. CI1'Y �it ; ci 1 Q. � STATE��ZIP S5�! S�
PHONE: � oZ - oZ D I ! �' �S � =S
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAI4tR,Y/NEW CONSTRUCTION STORIES
PERMIT TYPE � AD N ❑ GARAGE/SHED WINDOWS
O BASEMENT FINISH ❑ ROOF �L DRAIN TILE
�DECK C] SWIMMING POOL=��� �OTHEC �-.� �I� �'L.f/��L.��
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ ADDITION �_l_,,,,_._...-----------_...,,�_ � --�
MAINTENANCE/REPAIR MODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
' OR OFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELINjG SUBMTT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2, Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3 y List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl �offit ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing t�ie existing structures
❑ Aluminum � Trim and proposed project.
6� Other �7�Q �,c7�,��y�L. '87'�ascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OFENINGS�' es ❑No LOCATION OF WI OWS ,�A � FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF `/�� �C�7�`� MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & { f R O ` DOWS �/
TYPE OF WINDOW TO BE INSTALLED � 1� L 2NIIIvZBE �
ALL Nl�',L�'S AHL BA��ll UN VALUA'1'lUN, 11VC:LUll11V(i'1't1N l:U.�1' VN' LAl3VK A1VL 1V1AlEKlALJ:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�� ��Dl�_ �� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$� ��(.2S 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+6R= ftx$25=$
$ $450 Conservation Plan Review
$ � Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ Make checks pavable to: City of Fridley Attac
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL 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 o c s review and approval of p ans. �/�
SIGNATURE OF APPLICAI�� T�� PRINT NAME� k.1 � rG fi0ir ATE �� ZD —�:1
�,P��-� -- ���v' �/��•(� �763 �3 SS=� y�S
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