P - 46278Building BUILDINCs Pei7nit rlo.: " �
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY D�'�°a� �
763-502-4977 FAX EFFECTIVE I-1-2011
DATE � I� I�� YOUR E-MAIL ADDRESS � l.� I 1 G K. +► Je.C6l.(�Od�.(rL5 , CO1'�"�
SITE ADDRESS (� l� 3a C h�. ��.� t �� N�
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNERI NAME: ��SS l C 0.. `�ftiar e r,
TENANT pDDRESS: (o �0 3 U C.� 4 h�e� ►�d N� CITY N't '2tf STATE ' h ZIPJ'� ��..
PHONE: �O/ ;,� ,�.7Q�Co �'jU�J
CONTRACTOR NAME: ✓G10. RtlOf+�cW � �R�t.rnncy.l�\:na
SUBMIT A COPY OF STATE LICENSE #�O ;,� � LEAD CERT NUMBER N�- a5o3y ��
YOUR STATE LICENSE �f��
AND CERTIFICATE OF ADDRESS: 4��0 �YCl.tSjO'r 13\Vc� CITY`�Ji�.�pt7�t��.wt, STATEN�' ZIPS�j�{I�
INSURANCE pyONE q5�-a15��? FAX Ci,6� - �(a� - '
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAM[LY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADD[TION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH -43�tOOF ❑ DRAIN 'TILE
❑ DECK " ❑ SIDING ❑ OTHER
❑ SW[MMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � � 'f' �� �•c.�
S1ZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ' HOUSE ONLY
NUMBER OF SQUARES ��' ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. ' Existing Floor Plan
GARACES ❑ ATTACHED GARAGE 2. Proposed floor pian
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED NEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
O Vinyl OSoffit ADDIT[ONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
VVINDOWS 3. Energy Calculations
IN EXiSTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOii NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OP WINDOWS
ALC, FEES ARE BASED ON VALUAT[ON, INCLUDINC THE COST OF LABOR AND MATERiALS:
TOTAL JOB VALUAT[OlY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Controt
Park Fee
Sewer Main Charge
Total Due
$
$
$
(USING THE 1997 U.B.0 FEE SCHEDULE)
n , OCCUPANCY TYPE
� �1
:�'i
i �.•
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+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for � building permit and I aclrnowledge 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 wi11 be in accordance with the
approvec3 plan in the case of a ork which re uir s rea� w and approval of] �lans.
SIGNATURE OF APPLICANT �/ �+= � �(�PRINT NAME,UC�¢Nr1� ��I�JC DATE� .�D�/rI
APPROVAL INSPBCTOR SIGNATURE
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK