P - 44528Building BUILDING Permit Ivo.:
Inspections RESIDENTIAL APPLICATIUN Received By:
763-572-3604 CITY OF FRIDLEY t�at d� �,`� (� 2�
763-502-4977 FAX EFFECTIVE 1-1-2011 ��
DATE — YOURE-MAILADDRESS���QI��'�G�l/'Cq� S llsyJ �C�[J�
SITE ADDRESS �r]j� �� /}-' �E',� ��j � �jp) �"�
i,�lS r`.Fr^iiCA;1; ;S: i7 ^vWI'�EP. O:VTRrii:TGft
PROPERTY OWNERI NAME:
TENANT ADDRESS:_ ��i'�� CITY STATE ZIP
PHONE: �T6 3 — �/ - _��i ,��
CONTRACTOR NA�?"� o.
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE #_g� LEAD CERT NUMBER � �
AND CERTIFICATE OF ADDRESS:�b60 �AC/fA2�� �/O S CITY/'!%pL RO�E STATE ZIP 5536q
INSURANCE pHONE 5 = �i .� FAX — '�f
PROPERTY TYPE O SINGLE FANIILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/f�tEW CONSTRUCTION STORIES
PERMIT TYPE � �DI1'ION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FIIdISH ❑ ROOF ❑ DRAIN TILE
❑ DECK �{'�IDING ❑ OTf�R
O SWIMMINGPOOL
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ ADDITION
INTENANCElREPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ���"_ j��jT/f c'�'�L{,S� STF�'L
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE Fi GARAGE 1. Eacisting Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED IiEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyi offit ADDI1'IONS. & PORCHES SUBMIT:
❑ Aluminum Tnm 1. Site Plan/Survey showing the existing structures
�'bther .���L ascia and proposed project.
2. Two sets of conshucrion plans
WINDOWS 3. Energy Calculations
IN EXISTING OPBNINGS ❑Yes ONo LOCAITON OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED UN VALUATION, iNCLUDlNG '1'Ht� (:U�'1' Ur' LABVK A1VD MA 1"�HiAL�:
(USING THE 1997 U.B.0 FEE SCHEDIJLE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Dae � �
�$ ✓� o? /, o"Z S� See Back Page for Fee Schedule
$ 5% of Building Permit Fee
�, $� .�001 times the total job valuation
$ � 0005 x P'ermit Valuation Minimum $5.00
$ �-.r','�p 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 ( )
3? 1 Make checks aavable to: Citv of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acimowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and co e f the City of Fridley and with the Minnesota Construction Godes; that I understand this is not a
permit but only an applicarion for a ermit a worl s not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of' w 'ii d approval of plans.
SIGNATURE OF APPLICANT ` PRIN1' NAME C�i/,I-�.�Q/�¢ �t� ��Ii D '
APPROVAL INSPECTOR SIG ATURE _ M .