P - 47791Building BUILDING
Inspections Permit No..
763-572-3604 �' SIDENTIAL APPLICATION Received B
y:
763-502-4977 FAX CITY OF FRIDLEY Da�i����
EFFECTIVE 1-1-2011
DATE I p �I YOUR E-MAIL ADDRESS ICCtly1OI� f�}.f �
SITEADDRESS '�b Ciw�',X��PFLifF� �b� ��C�Ce,u{<
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
�OWNER ❑CONTRACTOR
NAME:_ �G �N€ $ L( S,r�- M T>I'C H�f{
ADDRESS: ( C�O C,� �,� q L�� ,�� CITY � i��t-y
PHONE: �i � �- ^ �I �'i p -- �j °3 � S STATE M JS ZIP S r`E � /
STATE LICENSE #
LEAD CERT NUMBER
ADDRESS:
PHONE CITY_
�SINGLE FAMILY/NEW CONSTRUCTION F�
❑ TWO FAMILY/NEW CONSTRUCTION c�rnnir�
ATE ZIP
❑ BASEMENT FINISH ^"v�'�J31LL u WWDOWS
❑ DECK � ROOF ❑ DRAIN TILE
O SIDING ❑ OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ SWIMMING POOL
❑ ADDITION
,�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �' ��F �t—�f#( �
SIZE OF IMPROVEMENT LENGTH
WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES I� ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
GARAGES ❑ ATTACHED GARAGE �• Existing Floor Plan
PROPOSED SIZE: ❑ DETACHED GARAGE 2• 1'roposed floor plan
PROPOSED HEIGHT: 3. List of structural members to be used
SIDING
❑ Vinyi
❑ Aluminum
❑ Other
❑Soffit
❑ Trim
❑ Fascia
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS & PORCHES SUBMIT
1. Site Plan/Survey showing the existing structures
and proposed project.
WINDOWS 2. Two sets of construction plans
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS 3 Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROV[DE U-VALUE AND
OPENING CHANGES & MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED
NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $ �USING THE 1997 U.B.0 FEE SCHEDULE)
Permit Fee OCCUPANCY TYPE
rian Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ .�1 SeP Rark P�s� �; ��e 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+6 ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ i Make checks payable to• C't f
� o Fr�dle Attach St�pulations
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 all work which requires review and approval of plans.
SIGNATURE OF APPLICANT ' PRINT NAME 1Ct'-N c" M�1Z A� t-� / j
APPROVAL INSPECTOR SIGNATURE DATE � 1�� I f(