P - 36921Building BUILDING Permit No.:�iv '� � (�
Inspections RESIDENTIAL APPLICATION Received By: r
763-572-3604 �
763-502-4977 FAX CITY OF FRIDLEY nat��t: :�j�
EFFECTIVE 1-1-2011
DATE�" / LQ "� � YOUR E-MA1L ADDRESS ijr c�..V��(i V1 �% ��V u.v�Q,.QLt}VhnG,v�� �'� •�,dV
SITEADDRESSS�°?��,e��i�2j{oR� �=�•�.
THIS APPLICANT IS: ❑ OWNER „jS�ONTRACTOR
PROPERTY OWNER/ NAME:�a [.�2 � SyA� � c,E �rz,c.vl�c �
TENANT pDDRESS:S�o7S$ N1A"[`CEQ�..bQl.� �iR. 1J'E� CITY 1"2� �C.'E `( STATE }�11J ZIP S�L� v2\
PHONE:`2 (93 ` S%� ' �% I3
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
N,�E: An�,a,,�c� CoMPA1.��FS
STATE LICENSE #�L1o'Z3 LEAD CERT NUMBER
ADDRESS:,g �-I.O a eEA�'� Rf-iL ��F %� CITY ��R � oC..E� STATE �t� ZIP S�S4 3�
.•
,JB�SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH ..i31ROOF
❑ DECK ❑ SIDING
❑ SWIMMING POOL
FAX
SIZE
STORIES _
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
AINTENANCE/REPAIR ❑ REMODELING
I
i DESCRIBE WORK BEING DONE:
I SIZE OF IMPROVEMENT L,ENGTH WIDTH
ROOFING ❑ HOUSE ONLY
` NUMBER OF SQUARESa2 I� s� ❑ HOUSE & GARAGE
GARAGES � ❑ ATTACHED GARAGE
PROPOSED SIZE: ❑ DETACHED GARAGE
� PROPOSED HEIGHT:
� SIDING
; ❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTIIVG OPENINGS ❑Yes �No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
❑ DRAIN TILE
❑ OTHER
HEIGHT
FT
BASEMENT REMODELMG SUBM[T:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCT[ON [NCLUDING DECKS,
ADDITIONS, & PORCHES SUBMIT:
l. Site Plan/Survey showing [he existing structures
and proposed project.
2. Two sets of construction 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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�, lt �I"7 .�° 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
$ �
$ D
$
$ 5
�
$
$
$
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$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks uavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 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 ork which requires review and approval of lans.
SIGNATURE OF APPLICANT R PRINT NAME�Rp1�i�avJ �1J��5i`� DATE �^ I(c� I�
APPROVAL INSPECTOR SIGNATURE