P - 45755Building BUILDING Permit r�o.: �' ` Oa
Inspections RESIDENTIAL APPLICATION Recei�ea By: !_��_
763-572-3604 CITY OF FRIDLEY � a�' p�-�,j
7b3-502-4977 FA� EFFECTIVE 1-t-2011 I���_l. U�'� "' "* ��U I!
DATE ��'Z�--1 � YOURE-MAILADDRESS �Q1jZb� �iAW2S��<1f�C 2YY1C� �� �L'�5 ,. C:��,M
SITE ADDRESS %�3 y C� L�] C i L LCI� Z..
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR ^
PROPERTY OWNER! NAME: ��h �y r �V � � L�v � �� 1 �c
TENANT ADDRESS:� �'i'lyi Ly,+r � Z i..c�Yl � CITY �i- ad � z� STATE.,M�IZIP S S`�� Z
PHONE: (�1"�-�� � %�`L�ct
CONTRACTOR NAME: �� ���'1'-�� �n R�.�(h� � �i �
SUBMI'T A COPY OF
YOUR STATE LICENSE STATE LICENSE # '� (�s�'�� `� � (� LEAD f:ERT NUMBER_ _ � AT � -Z. �fs �i 1 % — �
AND CERTIFICATE OF ADDRESS: Z`.-'�ZC �..c�'c �zY�'�'��1�f �V ��f1i1 t�l�i CITY 3 i i,' i:� `1 STATE�! ZIP. 5 i 1�
INSURANCE pHONE - - � � J � I FAX S � �" '7 ��
PROPERTY TYPE t�fsirlGLE FnNriL�irrEw corrs�rttuc�rtax sizE
❑ TWO FAMILY/NEW CONSTRUCTIQN STORIES
PERMTT TYPE fl�DITION ❑ GARAGE(SHED ❑ WiND(?WS
� BASEMENT FINIS}I $iROOF ❑ DRAIN TILE
Q DECK � SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: (� NEW HOME CONSTRUCTION ❑ ADDITION
,�"MAINTENANCE/REPAIR ❑ REMODSLING
DESCRIBE WORK BEING DONE: ��- '��,� C�'�3 �� �y�� f�� � T�
SIZE OF IMPROVEMENT LENGTH WIDTH HEiGHT S FT
RQQFING O HOUSE ONLY BAS�MENT REMODELING SUBMfT:
NUMBER OF SQUARES �! � HOUS� & GARAGE I. Exisring Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPpSED HEIGHT:
SIDIN FOR NEW CONSTRUCTiON TNCLUDING DECKS,
❑ Vinyl �So�t �1DDTCfONS & PORCHES StIBMIT•
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing strucri�res
and proposed project.
L7 Other CI Fascia 2. Two sets of construction plans
WINDOWS 3. EnergyCaiculations
IN EXISTTNG OPENINGS OYes �No LOCAITON OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
�R FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICICER ON WINDOW.
OPENING CHANGES &
TYPE OF WiIQDOW TO BE INSTALLED NUMBER OF WINDOWS
Ai.L Cl.C,.� Alil. liAA1LU VPI VALUAl�lV1V� 11V1,LU1l1PIli �l�l1E (:V��l� Ul'� LAKVK.AiVll MA�l�L''RIAI..S�
(USING THE 1997 U.B.0 FEE SCHEDULE)
JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
PIan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Totai Due
$
$
$
$ .
See Back Page for Fee Schedule
63% of Building Pernut Fee
.00t times the total job vaivation
.Q005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors}
$2230 per SAC Unit (Plans to MWCC for determination}
ft+6ft= ftx$25=$
$450 Conservation Pian Review
Fee Determined by Engineering
Agr�ment necessary ( ) Non Necessary ( )
Make checks payable to: Citv of Fridiev Attac
THIS IS AN APPLICATION FOIt A PERMIT-NOT VALID LJN'fIL PROCESSED
I hereby appiy for a building permit and I acknowledge that the information above is complete and accurate; that the work wil} be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; tfiat I understand this is not a
permit but only an application for a permit and work is not to stazt without a permit on site; that the work wili be in accordance with the
approved plan in the case li woC ich requue rev]�w and approval of� s. l
SIGNATUREOFAPPLICANT ti �jj�`��hf1,�� PRINTNAME_6)t�V.cl ��TY�tl.'CC!$C✓1DATE �U'Zif"II
APPROVAL INSPE�TOR SIGNATUI2E
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHAMCAL WORK