P - 48341Building BUILDING Pe�-,��t No.: Zb d�l � 1�j
Inspections RESIDENTIAL APPLICATION Received B}�'" �
763-572-3604 CITY OF FRIDLEY Date
763-502-4977 FAX ��� J � � � � � �
EFFECTIVE 1-1-2011
DATE ��( �� YOUR E-MAIL ADDRESS ` S l%M S �K . ��
SITE ADDRESS � �� t
THIS APPLICANT IS: ❑ OWNER � CONTRACTOR
PROPERTY OWNER/ NAME:
TENANT ADDRESS: CITY S STATE�ZIP ��L�
PHONE: '" �
CONTRACTOR NAME:�1`19 U V'(11�1+� 6(i ��VI S'�-�-'�1 f�l -��
SUBMIT A COPY OF `'�—�—
YOUR STATE LICENSE l ,np �` e,'y' i1'� /�
STATE LICENSE # � ? � 1 LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: ���o � „ Q. Iy1�� � IV�L ,7�` � l"K�ITY VLE�� STATE I�.�IIZIP �'/
INSURANCE p ONE' �� �� �O FAX � "� ( � a
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEl1' CONSTRUCTION STOR[ES
PERMIT T1'PE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK IDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODEUNG
DESCRIBE WORK BEING DONE: � "l✓ � � .� t'F" � �1�G � iM � � �
� G ( -{,
SIZE OF IMPROVEMENT LENGTH WIDT • HEIGHT SQ FT J��
ROOFING /,I� ., ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ✓� �HOUSE & GARAGE
1. Existmg 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 D6CKS,
❑ Vinyl r+'�.0 ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum,� j j'� V ❑ Tnm 1. Site Plan/Survey showing the existing structures
`�ther �. � \ ,���\,� ❑ Fascia and proposed project.
i� 2 Two sets of construcuon plans
WINDOWS 3. Ener�� 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 [NSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $�� � 1j�`�G �H� 1997 �UG��j ���E SCH OCCUPANCY TYPE
��
Permit Fee
Pian Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� 7—'i �. L5
$
$
$ �a l!�
$ _ Cl L
$
$
$
$
See Back Page for Fee 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+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks �avable 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 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 hAich re i s r vi�[R d approval of plan . j
SIGNANRE OF APPLICANT __��� j ` � � �`l �t/'� PRINT NAME �'�"�� �V DATE � �� ( r� I
APPROVAL INSPECTOR SIGNATU
PLEASE NOTE: SEPARATE PERMITS ARE REOUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK