P - 39367Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ����°} 1 LcJ t I
SITE ADDRESS
THIS APPL[CANT IS:
PROPERTY OW1vER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTiVE 1-I-2011
Permit No.: � � �:� � � � L
Received By:-�����-
Da��'��� � � ����
YOUR E-MA1L ADDRESS r�l'�'1F�Y7C'c1Y1GU71�7'uC�,�,Sry�n �C��nG� i(.C%vh')
❑ OWNER ❑CONTRACTOR
i: �M��iE::T prJla�.�.
A.DDRESS
1�o t�l, N � K
PHONE: 7�tr'�- ��� " ��i-��OQ
'F� � � t-� � STATE � � ZIP �
CONTRACTOR ('�oNZ�ae�.ra'b�� a�a A.ss��-��},-�5 u.fi
NAME: A'M��:i<�.� r.t - -
SUBMIT A COPY OF STATE LICENSE # ZO(ri31 ��o
YOUR STATE LICENSE � LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS:'�Z�S `���o �� �+� v� crTV M PL5 STATE M✓1 ZfP �Sy3U
1NSURANCE PHONE C�P i2� q�1 O-`�j;'�p Z- FAX _
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
Cl ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH � ROOF ❑ DRA(N TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION O ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: �£'F�flD�
SIZE OF IMPROVEMENT LENGTH WiDTH HEIGHT I`7Tat�`� SQ FT
ROOFING �s�
NUMBER OF SQUARES�
GARAGES �Z�Q `�
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
� Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WTNDOWS
NUMBER OF WINDOWS
BASEMENT REMODELING SUBMIT:
l. Existing Fioor Pian
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRllCTION INCLUDI?JG DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construcYion plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
-- _ _ - - - -- - - -- -- - __
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(LTSING THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VALUATION $ :�-�k32 -aa LA�,v � 3 t�o °�Mnr��+�r Z� OCCUPANCY TYPE
Permit Fee
D—�°.� IILV'
�
Fire Surcharge '-;
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �'1 —
l $
$
$ �
$
$
$
$
$
$
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 (Pfans to MWCC far determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks oavable to: Citv of Fridlev
Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL[D 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 cod of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application r a permit d ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of al orl�•whic s eview and approval of plans. q I�, Z� ! i
SIGNATURE OF APPLICANT 1 C�- U PRINT NAME'� IC�FZt'� PJ1��"R�5 DATE