P - 45218Building BUILDING Pe�it No' ' � I�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'�: .� � �
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE o2 YOUR E-MAIL ADDRESS Cl GC�iC.� Gv Sc°ICLro pLin 5• e0h'l.�
SITEADDRGSS p/U� fGL�I"MO�'� C�r�IL
THIS APPLICAI�iT IS: ❑ OVJNER �CONTRACTOR
PROPERTY OWNER/ NAME: �2pe��a..!-1 i�f1 nr� G� ��
TENANT ADDRESS: �'IUo7 �0�1� (�ar�'F C�r�ITY Fl`� STAT�� ZIP S�"��3L
PHONE: rJ G.�l � � �Z) " 4Sp�.�i
CONTRACTOR NAME: �ti0. RdOC;r1q C '�crnnc�\itx►
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE #'O� LEAD CERT N[SMBER N�- a5o3y- �
AND CERTIFICATE OF ADDRESS: y�OO ���j jt�r' C3�Vc� CITY�},�OU.is �rvt, STATE� ZIP55U�ri1
INSURANCE pHONE C15�' G i5 �i��, FAX CL6i - �( �� — `
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
� TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED 0'bViNDOWS
❑ BASEMENT FINISH ❑ 200F ❑ DRA(N TILE
❑ DECK ❑ SIDING O OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: `�P�(JIQ.('JL S Lc� i f�pu,j ��r' �LlY1Q. �Ze
S1ZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFINC ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
l. 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 ADDI7ION5. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ OCher ❑ Fascia and proposed project.
2. Two sets of consh•uction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS , Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRTBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & �t�_mQ.�
TYPE OF WINDOW TO BE INSTALLED NUMSER OP W[NDOWS J'
ALL FEES ARE BASED ON VALUATION, INCLUDING TNE COST OF LABOR AND MATERIfiLS:
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
SIN� THE 1997 U.B.0 FEE SCHEDULE)
� OCCUPANCY TYPE
$ See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �c .001 times the total }ob valuation
$ :� .0005 x Permit Valuation Minimum $5.00
$ y ,-��} $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 Fridley Attach Stiaulations
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 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 of work which require re�i and approval of plans�
/ .
SIGNATURE OF APPLICANT .�L.n_ y�d��A,�,��PRINT NAME JP�.n nec, G�� f� DATE 5��� / J
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK