P - 48130Building BUILDING Permit No.: (�%
Inspections RESIDENTIAL APPLICATION Reeeived By:,,�l�
763-572-3604 CITY OF FRIDLEY va�i�'Qcl� ���' ���'�
763-502-4977 FAX EFFECTIVE 11-2011
DATE %� -1,3 - �� u i/ YOUR E-MAIL ADDRESS
SITE ADDRESS ��-y 9 lh.Pyir-,GS ta+„ Qr n%E
THIS APPLICANT IS: ❑ OWNER �SCONTRACTOR
PROPERTY OWNER/ NAME: a,�
TENANT ADDRESS: �0�� �_�Idj.('�pL�`�1, �/ CITY�� �X/�.1 STATE ZIP
PHONE:
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # SG� S�{ =� S LEAD CERT NUMBER�T -�.�OSbf1- I EXP: � �. �U�
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �(�Io`�'(p � +i rI 1 o n� CITY tM���c 6yMt� STATE�/1%ZIP SS�%9
INSURANCE PHONE - - FAX - � a �0.1 �
PROPERTY TYPE J$) SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH � ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ S WIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
O MAINTENANCEIREPAIR E� REMODELING
DESCRIBE WORK BEING DONE:'j'2a.- -6�'F G„� I'G -✓00% Npvdt �,d u� �,G�,� �`s ✓�+�_
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES p�� ,� HOUSE & GARAGE �, Existing Floor Plan
�ARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
gIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
O Vinyl OSoffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT•
O Aluminum ❑ Trim REMOVED? �,1 YES O NO �• Site Plan/Survey showing the existing structures
❑ Other ❑ F�1e and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes ONo LOCATTON 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
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB_VALUATION $ _ _ OCCUPANCY TYPE
Permit Fee
Ptan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � 7. ol S 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 ( )
_$ �;'��. n Make checks payable to: Citv of Fridlev Attac
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
confotmance 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 �ork which requires r iew and approval of plans.
SIGNATURE OF APPLICANT --�'�S.—�___._ PRINT NAME IU � l.� �� g�, � DATE �% �' li ' a� ���
APPROVAL INSPECTOR SIGNAT[JRE