P - 44531Building BUILDING ���� Permit No.�� �� f�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'ct: � ll /
763-502-49�7 FAX EFFECTIVE 1-1-2011
DATE S O YOUR E-MAIL ADDRE S
SITE ADDR SS S �G � G ��
THIS APPLICANT [S: ❑ OWNER B�d� TOR
PROPERTY OWNER/ NAME: �
TENANT �pRESS: '%lSS' G i' CiTY ��.i ��G�STAT�ZIP SS4!32
PHONE: 7B ��3 G�
CONTRACTOR Na�1E:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NLIMBER
AND CERTIFICATE OF ADDRESS: 5a ��%J/Sc � _.7T,�r� CITY �J' STA'G�%/[lGIP�'
INSURANCE PHONE G � FAX
PROPERTY TYPE INGLE FAMILY/NBW CONSTRUCTION SIZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRA[N TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMiNG POOL
TYPE OF WORK: � N��HOME CONSTRUCTION ❑ ADDITION
H'ICIAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: t G�`o4i
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ' ❑ DETACHED GARAGE 3. C.ist of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCT[ON INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site PIaNSurvey showing the existing structures
O Other ❑ Fascia
and proposed project.
2. Two sets of consWction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS es ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF W[NDOW TO BE 1NSTALLED NUMBER OF WINDOWS
ALL r'�:LS AKL 13A�1:U U1V VALUA'1'lU1V,11VCLUllING '1'HE COST ON LAKUR ANU MA"i'ERlALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $_ /l, crtt'I'.� 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
$ ,��� as
$
$ i
$ 5�
$ s�, aQ—
$
$
$
$
$ _ . .� _
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Va(uation 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 paVable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building perrr►it and I 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 applica ' for a p ' and work is n t to start without a permit on site; that the work will be in accord ce with the
approved plan in the case o r h� requires revie and app v f /
SIGNATURE OF APPLICANT E��y/f �'//� DATE �%� G/�
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