P - 41840Building BUILDING Permit Ivo.: " (� � � ���
Inspections RESIDENTIAL APPLICATION Received By: �G
763-572-3604 CITY OF FRIDLEY �x��� �
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE /-7' �iI YOUR E-MAIL ADDRESS YJ l7Q{"� .k e�L-�r% r C��
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THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNERI NAME: ��W1C� STC�� Er2
TENANT ADDRESS: ���OLf ST /UC� CITY /"�<<9 �� STAT�LI ZIP S� �-
PHONE: � 3 �����' / �
CONTRACTOR NAME: TQ� �^'�� E g�
SUBMIT A COPY OF STATE LICENSE # O � LEAD CERT NUMBER �
YOUR STATE LICENSE p. �
AND CERTIFICATE OF ADDRESS: /�/Gl� �E^^� �'� S��� CITY��^'�'�p STAT�I�ZIP��Y-��
INSURANCE PHONE 9 � /7 Ot �- -O!'�'L FAX P�S�� "O.Z2I
PROPERTY TYPE GLE F /NEW CONSTRUCTION SIZE
� TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH '�ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: %C� O%f a,t9 S�Gi/rIGH t� Q� SI�F�'+��L f�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES _ i�� 0 HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
C�ARAGES ❑ 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 ❑Sofiit ADDI1'IONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of consduction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER QN WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL l�r;l�;.� AKr; KA.�l;ll VN VALUAllU1V� 11V(:LUll11V(i l'HL� (;Ual UN' LA1fUK AlVll MAl L+'KIAL,:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ G� OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ (Q .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ �O � Make checks aavable 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 the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicat' 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 cas 11 work '.�r re�eview and approval of pla�s2����,,,a, �� S��2d1/
SIGNATURE OF APPLICA PRINT NAME ,!S DaTE
APPROVAL INSPECTOR SIGNAT[JRE