P - 47298Building BUILDING Permit No.�� �'�'� 1,(�'
Inspections RESIDENTIAL APPLICATION Received By: Ww
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 11-2011 ��C� 1
DATE /� �-� YOURE-MAILADDRESS �����i'�'�' K�i�i
t� � � �%�"'r.i� i �?itif �C" /�-1 � > C-c,:z ,
SITE ADDRESS `=`�l ��iC✓Y 1'C � t'�iG C�.-Lt i tJ tr
THIS APPLICANT IS: ❑ OWNER '�CONTRACTOR � `� �
PROPERTY OWNER/ NAME: 1�C4#!�� �1J..��.'
TENANT ADDRESS: %�j� �'c":'r10E�'7L� G�-i ��= CITY �i' ��Ei( STATE %�� ZIP�
PHONE: / �� ' :�I V? " �'a `!��
CONTRACTOR NAME: IJN� G�'�-trL t_t��
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # r��.� ��(1(,7 �'p L�AD CERT NLTMBERMA�� .�%�`�—% EXP: [�i
AND CERTIFICATE OF ADDRESS:G2 _'3'v �'k�; /v�Ai v� `.��°+'��_*j' CITY /y71u.C{9 STATF�IcY ZIP��,�-�
INSURANCE PHONE '7i� �-�i C-- 3 i vr FAX !! �•` 1 Ci �l�,
PROPERTY TYPE �O'SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �� ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
O SWIMMING POOL
TYPE OF WORK: ❑ NEW HONIE CONSTRUCTION ❑ ADDITION
j�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: I�+C�-C�.i�^r
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �� j� HOUSE & GARAGE I. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCLA ADDITIONS. & PORCHES SUBMIT�
❑ Aluminum ❑ Trim REMOVED? ❑ YES L] NO �• Site Pian/Survey showing the existing structures
❑ Other ❑ Fascia ' and proposed project.
2. Two sets of construction plans
�'���'S 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 ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCF�EDU�,E)
TOTAL JOB VALUATION $_ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ��/, l,jJ See Back Page for Fe� Schedule
$ 65% of Building Permit Fee
$ 't .001 times the total job valuation
$ � .0005 x Permit Valuation Minimum $5.00
$ Sd� $5.00 (State Licensed Rasidential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ . Make checks payable-to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VAj,ID 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 permi, nd work i to stari without a pennit on site; that the work will be in accordance with the
approved pian in the case o ` }equir �• view d approval of plans. °
SIGNATURE OF APPLICANT PRINT NAME m��%C R• L�A����,r2� DATE �� �-'-'-� �
APPROVAL INSPECTOR Si ATi
PL