P - 62692Building BUILDING Permit No.: �I,�'ti{5111 �
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date��0: APR 1'� ��1
763-502-4977 FAX EFFECTIVE 1-i-2012
DATE l,� � L YOUR E-MAIL ADDRESS�'�� �'�" ��?C C', C, �� l� \ I��!� S 1�'1 y�I . Cd✓L�
SITE ADDRESS � � I � � R ti Z. '� 'S �' 'N � E
THIS APPLICANT IS: ❑ OWNER �NTRACTOR
PROPERTY OWNER/ NAME: R� W L. I�� L
TENANT ADDRESS: �J� �'�'1 �14tc3 �"F" N= �. CTTY ��2/��I � h STATE%� IP��� Z
PHONE: .�n.3 � I�� C� � �
CONTRACTOR NAME: �XC C.1 3�.�. � 1 r i�
SUBMIT A COPY OF STATE LICENSE #�� � Co ���� �j '�- LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �d o�t� 8I �; �"�i'�Y`� '�" CITY_�/ �CflJ/r��6► STATB�%/ .,IP�
INSURANCE PHO E I� � Gr FAX
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTfON SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDIT'ION ❑ G�A GE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �'i�pOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION O ADDITION
❑ MAINTENANCE/REPAIR � j]�R�MODELING
DESCRIBE WORK BEING DONE: L�Z�l'
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
R OFING n ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES aC � ❑ HOUSE & GARAGE 1. Existing Floor Plan
�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 ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? O YES 0 NO 1. Site Plan/Survey showing the existing structures
and proposed project.
O Other ❑ Fascia 2. Two sets of constrvction plans
WINDOWS 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
ai.i, rr.r,� Eucr, 1sAa�li VPI VALUAl1V1V,11VC:LUL1Nli IHL�' (:V51 VN' LABVIi ANl) MA'1�EKIALS:
NG THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION $_ _� � �� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Suroharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum or .50
$ $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ ___ _;,1, Make checks payable to: City of Fridley 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 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 which requires review and approval of plans ��/J�� f
SIGNATURE OF APPLICANT �- � — PRINT NAME ���% / �L' k��/ �/ ZDATE ✓� �_
APPROVAL INSPECTOR SIGNA RE