P - 36714Building BUILDING Permit No.: Z
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vat�dll�A� 1���]��
763-502-4977 FAX EFFECTIVE I-1-2011
DATE YOUR&M_A/ILADDRESS �IL1`'LCX-�f bl.tl� M cl�� CO/`'�
5IT'E ADDRESS lG �i1 �'iif.t G%i� 'Sf .���• i f I�[ l� �l�-� J���'"3�
THIS APPLICANf IS: jA'�WNER OCONTRACTOR
PROPERTY OWNER/ N,�: � a� /�.[�,t r J?
TENANT ADDRESS: lQ I� I.LUO �J'� � N• L. CITY r" /���lit..�[� STATE I��P JJ� .�
rxor�: 7G 3 - �SG °'S9la !
CONTRACTOR N,�:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE p�
PROPERTY TYPE �B'SINGLE FAMILY/NEW CONSTRUCTION SIZE i OI�
❑ TWO FAMILY/NEW CONSTRUCTION STORIES /
pERMIT TypE ❑ ADDITION � GARAGF/SHED ❑ WINDOWS
❑ BASEMENf FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OT'�IIIt
❑ SWINIIvIING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
(a301AINTENANCEIREPAIIt 0 REMODELING
DESCRIBE WORK BEING DONE: IUC,t.c1 �
SIZE OF IMI'ROVEMENT LENGTH WIDTH TiEIGHT FT
ROOFING �j( HOUSE ONLY BASEMENT REMODELING SUBMIT
NUMBER OF SQUARES � ❑ HOUSE 8c GARAGE 1. Eadsting Floor Plan
G GES ❑ ATTACi�D GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structu�l members to be used
PROPOSED HEIGHT:
SIpING FOR NEW CONSTRUCTION INCLUDINCI DECKS,
❑ Vin 1 /+�DITIONS & PORCHE3 2��TT•
Y ❑Soffit
❑ Al»mirn�m ❑ Trim 1. Site Plm�/Su[vey showing the existix�g Sh1eCtLII'es
❑,Other ❑ Fascia �d ProPo� P�.1�•
2. Two sets of conskuction pla�
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINL)OWS FOR WINDOWS — PROVIDE U-VALLTE AND
OR FOR NEW OPENIlVGS-DESCRIBE SIZE OF MANtJFACTURE STICKER ON WINDOW.
OPIIVING CHANGES &
TYPE OF WIlVDOW TO B$ INSTALLED IVZJMBER OF WINDOWS
ALL FEE5 ARE BASED ON VALUATION. INCL[TDiNf.' TRE ('.nST nF T,AR(1R ANiI MATF.RTAi.c.
TOTAL JOB VALi
Perrnit Fce
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sew� Main Charge
Total Due
(USING THE 1997 U.B.0 FEE SCI�DITLE)
$
$
$
$
$
$
$
$
$ --�q�-�-
$ !O� �
OCCUPANCY TYPE
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Vatuation Minimum $5.00
$5.00 (Staxe Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination}
ft+ 6 ft = ft x$25= $
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks navable to: Citv of Fridlev AtrA�
THIS IS AN APPLICdTION FQR A PERMIT-NOT VALID UNTIL PROCESSID
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 pernut on site; thai the work will be in accordance with the
approved plan in the case of all work w'ch r � es review and approval of plans. �%
APPROV�AI.EINSPECTLOB 3TC'.NATi1RF-�'�--�--��1�', PRINTNEIME��l-�-1-4 r�DATE�7�Ir3 /I I