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Building BUILDING Perrnit Ivo.: � $
Inspections RESIDENTIAL APPLICATION Recei�ed By: �_
763-572-3604 CITY OF FRIDLEY vat 'd:
763-502-4977 FAX �� '�
EFFECTIVE 1-1-2011
DATE YOUR E-MAIL ADDRESS �'ji/�[t ,,�/jC/�i�r�psi�a (,�Ji i,.al�bcuCDnCOi�srr�n. C O w►
srrE.�wnxESS ��'O�f' �asf c�,,-�'��av �
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: '
TENANT ADDRESS: S O � s Cr[y_ �r�c�� STATE�ZIP SS�l3�
PHONE: ��- 9S/D— q/�i�o
CONTRACTOR NpME:���� Con��Ls cy( �Ifj�y�� �
SUBMIT A COPY OF STATE LICENSE # ('J%`'p3 SR %3 LEAD CERT NUMBER T
YOUR STATE LICENSE �
AND CERTIFICATE OF ADDRESS:�9/ ���4s'�� CITY . STA'i'E�IP SS�
INSURANCE pHONE — 9O 'iO O FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILYR3EW CE?NSTRUCTION 3TORIES
PERMIT T'YPE � �DTI'ION ❑ GARAGE/SHED WINDOWS
� BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ��tEW HOME CONSTRUCTION ❑ ADDITION
j� MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �� � � j
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT �
ROOFING ❑ HOUSE ONLY BASEMENT RFMOD_F.i INC, SL1�3MIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan
G�RAGES ❑ 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 ADDITIONS_ & PORCHES SUBMTf:
❑ Aluminum 0 Trim 1. Site Plan/Siuvey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
R'IND�L 3. Energy Calculations
IN EXISTING OPENINGS �'es ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & s
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
Ai,i. rr,�a aicr, is.�ar,L utv vA1.Ua11Viv, liV(:LUll11V(� l'Hl: C:US"1' UF LABUR AND MATERIALS:
�(USING THE 1997 U.B.0 FEE SCHEDULE)
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ {�'�. L� 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$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$_ � ' � � Make checks payable 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 th City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application erm' ork i not start without a permit on site; that the work will be ' ordance with the
approved plan in the case of approval of plan r '�/!
SIGNATURE OF APPLICANT 1��j1�1�E i%�I�,_ ,Ll�LJS�J DATE
APPROVAL INSPECTOR SiGNA JRF. �/ / .(/�/�/