P - 48327_�' 11�'�` %'� `_ ) � �
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Build;ng BUILDING Permit No.:
I��spections RESIDENTIAL APPLICATION Received By:'
763-572-3604 � 3�y � � r j �'
763-502-4977 FAX CITY OF FRIDLEY D�(����':� � �
EFFECTIVE 1-1-2011
DATE ';J` t /� ' YOUR E-MAIL ADDRESS
s►rE A���ss _ _ f f � i 1. ��� ,i(.< _ �� �,. 1 ��� �`�_�
1'HIS APPLICANT IS: ❑ OWNER `jZ�CONTRACTOR
PROPERTY OWNER/ rra.ivtE: ; . �!l����,r � r1 ��� � � �2 �<�,�� � r-�'i b'C C:� ��; ,v �
TENANT r , „ —� ,� � �: . .
ADDRESS � l� �- �/ �..t_ `��/ r zt`_ CITY I�-1 �� ��, STATE%f�iF„!�ZIP ,—�_ �--.�!
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PHONE: :��..> o � %� �.: " ;`/A _!
CONTRACTOR NAME: � %: :?` ' °�"? �, � �; ii" �'k' l ," C.� �-�J��':�
SUBMIT A COPY OF / � •-- , -
YOUR STATE LICENSE STATE LICENSE # �RC..��l ��l� � LEAD CERT NUMBER '� /��"��� '� -!. t��
( �. CITY r.�— k.' ;% �� ,ur STAT �fj`�ZIP �-� �.�.'<'�
AND CERTIFICATE OF ADDRESS: � � I � :�� `�;��'f � ��"- `''� ! � �,�' F,� '�
P'vSli�iNi:E PHONE J ' ��� 'v'C-� �r< FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTTON SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�vIAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: t ��t �-� � Cj � " '; ? ' ' -'.. ,. �� t' '.�: %
SIZE OF IMYROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE �, Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan --
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of suuctural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other __ ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS�Yes ❑No LO AT10N OF WINDOWS //.. f" FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS- ESCRIBE SIZE OF �i`l'�; �- Ll" /; ��_'� ?_,Y �+-%17?::)� { MANUFACTURE STICKER OI�r WINDOW.
OPENING CHANGES & /
TYPE OF WINDOW "I'O BE INSTALLED ��1.1�}�`' f�)(.JX: NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUAT N, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
-Surcharge
License Surcharge
SAC Charge
'Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
(USING THE 1997 U.B.0 FEE SCHEDULE)
;�`:,:>',,,,°`��; _ OCCUPANCY
� / � . �'-: �
$
$ �
� <:
$ f.., �
$
$
$
$
$
$ ,. , `m. �
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)
fr+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: Citv of Fridlev Attach
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 an work i�s t to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all work wh'ch requ es r�G'�w and approval of plans. ,
SIGNATUREOFAPPLICANT ' ' � � ;'-��� � _) TNAME ,!`�� ;�;� ��%'.�:�i'�v DATE � ��_�`� ��
APPROVAl_ INSPECTOR SIGNATURE � � '
PLEASE NOTE: SEPARATE P A REOUIRED FOR PLUMBING_ ELECTRICAL AND MECHANICAL WORI�