P - 5046913�.`��
Building BUILDING Permit Ivo�7�.Y'?—C�iO S3
Inspections RESIDENTIAL APPLICATION Received By: ��
763-572-3604 CITY OF FRIDLEY Date Rec'd: �-'�-'�
763-502-4977 FAX EFFECTNE 1-1-2012
DATE �9. . I• Z�!:�Ji YOUR E-MAIL ADDRESS I
SITE ADDRESS LO !� S
THIS APPLICANT IS: ❑ OWNER '�ONTRACTOR
PROPERTY OWNER/ NAME: P!/18
TENANT ADDRESS: �GL�$ ___CITY STATE ZIP
PHONE: 0• 2 �
CONTRACTOR NAME:�� CGr�S W/�o%.� fS�d��N
SUBMiT A COPY OF STATE LICEN� # U � LEAD CERT NUMBER 1VfT Z$Z%%'I EXP: N.(o .ZD IS
YOUR STATE LICENSE
AND CERTIFICATE oF ADDRESS: /N� yD �i4laXie �QD clTV Vq,I STATE�ZIP /2
iNSURANCE pHONE J'f Z• $ I� C� FAX Z• /. %Z�
PROPERTY TYPE L�iNGLE FAMILY/NEW CONSTRUCTION SIZE £u� — 3— �Q
❑ TWO FAMILY/NEW CONSTRUCTION 5TORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPATR ❑ REMODELiNG
DESCRIBE WORK BEtNG DONE: �p/!t,(Q � tui^��j �h C.�G� � 9?G�iI'V.S• p/�tGG 1 wi�+w W�T o c�s�/t fls�� ��`s ���—
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE B.4SEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
ROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
ROPOSED HEIGHT:
SiDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 1. Site Plan/Suroey showing the existing shuctures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calwlations
iN EXISTiNG OPENINGS cs ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENiNGS- ESCRIBE SIZE OF h,p ,''� oa/ s��b�1 MANUFACTURE STiCKER ON WINDOW.
OPENING CHANGES &
TYPE OF WiNDOW TO BE INSTALLED ::��(,�. pD � MBER OF WINDOWS
ALL FEES ARE BASED ON VALU TION. INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION
Permit Fee
Plan Review
IFire Surcharge
Surcharge
License Surcharge
SAC Charge
� Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
iUS—ING THE 1997 U.B.0 FEE SCHEDULE)
l�7 C7 • °" OCCUPANCY
$ ( o`�� . 1� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ , .001 times the total job valuation
$ . Q .0005 x Permit Valuation Minimum or .50
$ ��v(� $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (P1ans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ greement necessary ( ) Non Necessary ( )
$ 1 n Make checks navable to: Citv of Fridlev Attach
THIS iS AN APPLiCATiON FOR A PERMIT-NOT VALID LTNTIL PROCE5SED
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 C'ty of Fridley and with the Minnesota Construction Codes; that I understand this is not a
�ern�it but only an application for a pe it and w is not to start without a permit on site; that the work will be in accordance with the
pproved plan in the case of a wor which •equ' e review and approval of plans. ,-/, 'I'
IGNATURE OF APPLTCANT ' PRINT NAME �� I�ws W'��dl DATE I7_ �L�� � Zd��L
APPROVAL INSPECTOR SIGNA E
PLEASE NOTE: S ARATE P S ARE REOUIRE FOR PLUMBING. ELECTRICAL AND MECHANICAL WORK