P - 46284Building BUILDING Permit No.: -
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY D����:u ��������
763-502-4977 FAX
EFFECTIVE 1-I-2011
DATE L6�+ Z� L YOUR �MAIL ADDRESS ��� �/`T � R� " �'�% S�V ��"�
sITE ADDRESS �3 /3 ^1 �}�D R � `ZA/� i'Tt �' V� N �
THIS APPLICANT IS: ❑ OWNER .�L�ONTRACTOR
PROPERTY OWNER/ Np�: '`'/Ns�. �- P�riv yS � F V jZ (,pN�
TENANT ADD�ss: S3 3� H"o R 1 Zow Ai�Cr►-Y 'F R 1 O c.E � STATE MNLIP , J�2 J
PHONE: �� 3" S% 1°"' S�� b
CONTRACTOR NAME: �H"� (!I L � � R
SUBMIT A COPY OF STATE LICENSE #�T I S� LEAD CERT NUMBER
YOUR STATE LICENSE
ANDCERTIFICATEOF ADDRESS: y�� � V� �iQ'R-Y� R� CITY�H�RFi(/J�L•�TATE/bM�IP 5�7��.
INSURANCE PHONE 6I �i" % J� '� SQ ZO FAX
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION slzE
❑ TWO FAMII.Y/NEW CONSTRUCTION STORIES
PERMIT TYPE ��DITION ❑ GARAGF/SHED 0 WINDOWS
❑ BASIIvIENT FINISH �20pF ❑ DRAIN TILE
❑ DECK O SIDING O OTHIIi
❑ SWIIvIlvIING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �� — Rt7O �
SIZE OF IMPROVF,MENT LENGTH WIDTH HEIGHT FT
R FING a� ❑ HOUSE ONLY
NUMBER OF SQUARES /•� ❑ HOUSE & GARAGE BASE[v1IIVT REMODELING SUBMIT:
1. Facisting Floor Plan
GARAGES 0 ATTACHED GARAGE 2. Proposed floor plan
PROP05ED SIZE: �DE'fACHED GARAGE 3. List of structural memb�s to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSIRUCTION INCLUDING DECKS,
❑ Vinyl OSoffit ADDITIONS. & PORCHES SUBMIT:
❑���� ❑ T� 1. Site Plan/Survey showing the existing structures
0 Other �'Fascia � prOp°� p�O���
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes ❑No LOCA1'ION OF WINDOWS FOR WINDOWS — PROVIDE U-VALLTE AND
OR FOR NEW OPININGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLID NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
Total Due
$
$
$
$
$
$
$
$
$ —
$ •
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Pernut 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
Ageement necessary ( ) Non Necessary ( )
Make checks uav�ble to: Citv of Fridlev Attach
TFIIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby appiy for a building pernut and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes the City of Fridley and with the Minnesota Construction Codes; that I understand tiiis is not a
permit but only an application fo d 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 wo whic uires review and approval of plans.
SIGNATURE OF APPLICANT PRIIVT NAME �G Tr S�"� R,� DATE !o ��-� � t I
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBIN , ELECTRICAL AND A�IECHANICAL WU12K