P - 48087Building BUILDING Permit No.: �r G('� �j
Inspections RESIDENTIAL APPLICATION Received By: 9�°�
763-572-3604 --
763-502-4977 FAX CITY OF FRIDLEY D������ � °
EFFECTIVE 1-I-2011
DATE S� �1 �1 1 YOUR E-MAIL ADDRESS Ad'� 1(.,� .���� ��,-�o� ���Z m n C.�.S
SITE ADDRESS (p S lpS LC,�C i C� l..�r� t�_I�I, c �nL�l9-����
THIS APPLICANT IS: � OWNER ❑CONTRACTOR
PROPERTY OWNER/ NqME: �t,t, ��.( �r�
TE1vANT ,�DRESS: (�5 (o t�,GiG�- �-d-�� l�(� CITY �n,� �,Zy STATE�ZIP SS��
PHONE: ��'�i SV) I-'�'i S to �63 - So6 � b6 Z
CONTRACTOR NwME:
SUBMIT A COPY OF
- YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE p,q}t
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINiSH � ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING � OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITtON
❑ MAINTENANCE/REPAIR '� REMODELING
DESCRIBE WORK BEING DONE: Y�.o,t,U A. D�hp�-� GtrirlLU�4-�i
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING S.IJBMIT�
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structura�members to be used
PROPOSEb HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDiNG DECKS,
p umy� �Sofft ADDITIONS. & PORCHES SUBMIT•
O Aluminum ❑ Trim l. Site Plan/Survey showing the existing structures
���' O Fascia and proposed project.
2. Two sets of construction plans
WIlVDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo 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 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
P(an Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totai Due
$
$
$
��a ,��_�
$
$
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+ 6 ft=1�f ,.�— ft x$25= $ 3�s— c�v.� �b�u, ��� L
$450 Conservation Pian Review ,.rQ� ��(�,r.
Fee Determined by Engineering �• Itk} .y���—
Agreement necessary () Non Necessary () ��'+�0.d�r— s•.�a�.��cr on ri �
Make checks payable to: City of Fridley Attach Stipulations Sj
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 all work which requires review and approval of plans.
SIGNATURE OF APPLICANT `YY��C,�n�,�,�fLgjP1tic�j PRINT NAME il.l� C(�p�(,� [y� ,/�rC3�S DATE SI23I! I
APPROVAL INSPECTOR SIGNATURE
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