P - 48116Building BUILDING Pe�nit Ivo.:�� �� ��:�
Inspections RESIDENTIAL APPLICATION Received B��`!'� I�
763-572-3604 CITY OF FRIDLEY Da��'cfi':' '``�
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE s S�� � YOUR E-MAIL ADDRESS ��V I�Y1 ti� 7aY1 �l � U-I YI C.�fJYY't
SITEADDRESS p%D� /r(a141 S'�' �l/�. / /lCllet/ %%?l1� �.?l�
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ N�:
TENANT �DRESS: ��D✓t %�I�I►'I SrI`�' N� CITY STATE!�!V ZIP S 3Z
PHONE: %�.3 " � � ' ��,3 �
CONTRACTOR N�: San d�u. on s�ru�fi o� .T.� �
SUBMIT A COPY OF STATE LICENSE # 7 Z S LEAD CERT NUMBER I11i�lT'" ZSSSS' �
YOUR STATE LICENSE p r
AND CERTIFICATE OF ADDRESS: 97Z 7 3 '�7 CITY '00 y j STATE�i�%/VZIP,�J�
INSURANCE PHONE FAX ^ D°" 96 dV
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FII�IISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING j�OTI�R
❑ SWIMMING POOL �
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �TREMODELING
DESCRIBE WORK BEING DONE: t bri k ou c "� �e W t Cl,c-� �he 5'fiN�—
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT v
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NLJMBER OF SQUARES ❑ HOUSE & GARAGE 1. Exisring Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural 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
0 Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculallons
IN EXISTING OPEIVINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPEI�IINGS-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:
(U ING THE 1997 U.B.0 FEE SCHEDULE)
AL JOB VALUATION S� ZZ�. OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � ���
$
$ �'
$
$ �
$
$
$
$
$ ,
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$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable 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 d des of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application fo � ermit 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 o w which requires review and approval of p� ,
SIGNATURE OF APPLICANT PRINT NAME I„`�� �+ �4 ^Z.� v DATE S" S"�(
APPROVAL INSPECTOR SIGNA