P - 46285Building
Inspections
763-572-3604
�63-sa2-49�� F�
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2011
Permit No.:��� �
Received By.
Date Rec' d:
DATE io `ad' �� YQUR E-MAIL ADllRESS __ I�r� S 0.r.d t- � L� ar-ci '� u�. � '
I-�, � �ovr�CUS-� �
SITE ADDRESS 'rJ �C� ���' [f. v ✓ IP� �,, � .c- r`yrt' "" t�:�
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
❑ OWNER
NAME:
ADDRESS:c���� C lPC,�rVi-Pi�J 51�ren'� CTTY ��-r� �e � STAT�/v ZIP ]����
PHO�: �r�_ -,�3 -a$ go
CONTRACTOR N,�:� �� C����„" ��
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE #�� � ��(�,'� �� LEAD CERT NUMI3ER '(��r — I O� S�o �— �
AND CERTIFICATE OF ADDRESS: 131-} ��I �►JU„�Cl�n �1 �„�(� �� �� CITY iiv�v� STATE(�My ZIP�3_�
�.S�NCE' PH�� �n� ( - �a L. - l/ Gi �� Ff�' i/15 ( - � a-� - -f G �i �
PROPERTY TYPE
PERMIT TYPE
�SINGLE FAMILY/NEW C�NSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ ADDTI'ION ❑ GARAGE/SHED
❑ BASEMENT FIl�IISH �OOF
❑ DECK ❑ SIDING
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: '❑ NEW HOME CONSTRUCTION ❑ avnrrrox
�MAINTENANCEIREPAIlt ❑ REMODELING
DESCRIBE WORK BEING DONE:�e Ov � "'�' � p � cxCS�-. 51�� r,� 1eS �
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFiNG �j� ❑ HOUSE ONLY
NUMBER OF SQUARES 13 s Cj� T�vl2s� �;LQUSE & GARAGE �' g� 3�
�ARAGES V ❑ ATTACHED GARAGE
PROPOSED SIZE: � � � 'GG/'C���ETACHED GARAGE � 3� ,t.,��
PROPOSED HEIGHT:
SIiUING
�Iinyl
Aluminum
Other
��.- +- Gar°-��
HEIGHT SO Ff
BASEMENT REMODELING SUBMTT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCITON INCLUDING DECKS,
❑Soffit .�DDTITONS_ 8t PORCHES SUBMIT:
❑ Trim 1. Site PIan/Survey showing the existing stiuctures
❑ Fascia and proposed project.
2. 'Ibvo set4 of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS – PROVIDE U-VALUE AND
OR FOR NEW OPENIitGS-DESCRIBE SIZE OF MANIJFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUM$ER OF WINDOWS
ALL FEES ARE BASED ON VALUATIUN, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $ �S�G TfHE'199�7OU.OB.0 F�EE SC �CUPANCY TYPE
Pernut Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$
$ O
S
$
$
$
$
$
See Back Page for F� Scl�dule
65% of Building Permit Fee
.001 ti�s the total job valuation
.0005 x Permit Valuation Minimum �5.�
$5.00 (State Licensed Residential Cotrt�actors)
$2230 per SAC Undt (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Cflnsexvation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
THIS IS AN APPLICAITON FOR A PERMTT-NOT VALID UN'1'IL PROCESSED
I t�ereby apply for a building permit and I acknowledge that the information above is �mplete and accurate; that the wori� will be in
confarma�e with the ordinances and codes of the City of Fridley a� with the Minnesota Const�uction Codes; tbat I understan�d this is not a
pemrit but only an application for a permit and work is xwt to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all work which requires review and approval of plans.
SIGNATUREOF APPLICANT �,I� ��-��, �_�N�-� PRINTNAMEK.(r.15�'TE./� /V�. ���_DATE � I Z� 1(1.