P - 46808From: 1 952 88T 7009 Page: 2/7 Date: 11/17/2011 7:23:42 AM
F f0m: Lt5 JUNt� hiUUr I NCi 1 y�"L tftSl /UU'y 11/1 Il'CUl 1 Uti: lb
Building
Inspections
763-572-3604
763-542-49'T7' FAX
DATE 1 � ,.r I � '� I
SITEAADRESS [�'�..� �
THIS APPLICAN'C IS:
TENANT
e❑
�f4Uy t'.UU'L/'UU'/
BUILDING permit tJo.: °�-�.t
RESIDENTIAL APPLICATION Received By:
CITY 4F FRIDLEY vate��:��
EFFECT'[YE 112Q11
YOUR�ivtAILADDRESS C�'�IC� I CS f�vI �'S J'"�:a��'iFC�+ r�G+��..�
��> .1 /a+ � % F' r7 J
�`8in Yi��
i�_ t�� �:� -
�
0
e.n,inc: fi..c . . crJ�.�+..`7 � Vc [�r 7 -� � . -4C� .
SUBMIT A COPY OF STATE LICENSE # � pJ' �CvC� LEAA CERT
YOUR STATE LICENSE y . � �
AND CERTlFTCATE (?F ADDRESS: �7''�'II G/J . Lf'�"�' �� Ci�i
INSURANCE PHONE � ` 9�..7 • �i "r5 i - � .,� t g� � ��
PROPERTY TY�E CI SINGLE FAMI[.Y/NEW CONSTRLtCTIOx SIZE
L] TWQ FAI4IILY/NEW CONSTRUCITON STOEtIES
PERNIIT TYPE Q ADDI'flON ❑�AG AGF1SHEll O WITTDOWg
O BASEMEN'C FIi�iISH F Ci DRAIN TII.E
❑ DE�K SID1NG ❑ OTHER
❑ SWIIvllvflNG POOL
T'YPE fJF WORK: D NEW HOME COMSTRUCI70N ❑ ADDITIOIV
TENANCFJREPAIIt D REMODfiLTNG
DBSGRIB& WpRK BEING pOI�tE: Pc.vl" G� . J" t' �"t%�
N� OF SQUARES '7 O
GARAGES
PROP05ED SIZE:
PRQPOSED HE[GHT:
SIDING
0 Vinyl
❑ Atuaninum
❑ Other
WWDOWS
1N E7�IST2NG OPENING3 ❑Yes iJNo
OR FOR NEW OPENIPIGS-DESCRIBE SIZE OF
OPEMING CHANGES &
TYI'E QF WINDOW TO BE II�ISTALLELI
ALL FEES ARE BASED ON V
Flan Review
Fire Surchaxgc
Surcharge
Licsnse Surcharge
SAC Gharge
Curb Cut Escrow
Ero�ion Controi
Park Fee
Sewer Main Charge
❑ HOUSE ONLY
❑ �iOUSS & GARAGE
O ATTACHEp CrARAGE
❑ DETACHED GARAGE
��� �����'/
BASfi NT R��tpD ..i N'[; Rt rxtil�rlT•
t. Existing F1oor P18n
2. Proposed floor pinn
3. List of struchual members to be used
FOR NEW (;QNS'£RUCITON INQ,UDING I)EGT{S,
OSof6t SIDING/SUFFII'/FASGIA ADDI170NC .w vnuru�S cTtRnarrv
Q Trim REQUIItED? O 1'�S �� 1. S tte Plan/Survcy showing the existing sG�wKures
D Fascis and proposed' project
2. Two sets of conslruction ptans
3. Energy Galculations
L�CATION OF WINDOWS FOR WINDOWS—FROVIDE U-VALUE AND
MANUFACTUTtE S3ICKER f1N WTNDOVI.
NUMBEROk' WINAOWS
LUATION, INCLUDING THE �OST `OF LABOR AND MA'I'ERiALS:
SING THE 1997 U.B.0 FEE SCHEDULE)
-9� I'G 5� LS Sec Back Page for Fee Schedule
$ 65°10 of Building Perm.it Fee
$ ��� .041 times the tofial job valuation
$ � _ .0005 x Per�nit Valuation Minimum $S.QU
$ $5.00 {State i,icensed Residentiai Confi�actors)
$ $2230 per SAC Unit (Plans to MWCC far deterrnination)
$ ft+6ft= ftx$25=a
S $450 Gonservation Plan Review
� Fee Determined by Engineering
$ Agretrr�ent necessary { ) Non Necessary ( )
THTS IS AN APPLICATION FOR A PERMIT-1VOT VALID UNT'IL PROCESSED
I fiereby apply for a building permit and I acknowledgt tha# the information above is complete snd accurate; that the work will be zn
confortnance �ith the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
parmit but only an appiieation r pe ' sn work is not to s ithout permit site; that the work will be in aceordaace wiih the
approved plan in the case of at h iras review d rovat , t %
5IGNATURE OF APPLICAN'f PRTN'f N p ` 4Z�, DATE�� %� I!j ,
APPROVAL INSPECTdR SfCrNATURE
rr �-r ,�
1�