P - 44529Building BUILDING Permit No.: u�, �V
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY �����'� j! � 0 201
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE ��7 ��� YOURE-MAILADDRESS %��-�� �% �%��!'�l� • C�O'Y/^)
SI�, ADD�SS /�'7Co M.55 % ss ,��� .�t �I �,� Q�,, til N S�5 � 3�--
THIS APPLICANT IS: ❑ OWNER CONTRACTOR
PROPERTYOWNER/ NA1�E: Or.'lE1 f.� �1'rtrn.�-/-ma-.v
TENANT ADDx�ss: 7SI S� T�m�a � Ytt C.� CITY �J L� -LN STATE�� ZIP SS 7,3�
PHONE: � to� ' �ff HJ �qS 7 `�
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # I Co LEAD CERT NUMBER !4-T "� I�'% " I�
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: g�o� r/ ,P�YI�1 /�i�/tIt CITY ��Q� STATE Il' �'J`� �3
INSURANCE PHONE io.� "" 7�lJ �� y FAX 7(o '7 O �" � 9 5
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED ❑ wlrmowS
❑ BASEMENT FINISH `�OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWINIMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDTTION
�viAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DON6:���R-R.. nGG � � d�" �li�Lf,n /%�� p � f uu�
SIZE OF IMPROVEMENT LENGTH W1DTH HEIGHT S FT
ROOFING HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES __��___ ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES O 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 ADDTTIOI3S. & PORCHES Si3BMIT:
❑ Aluminutn O Trim i. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
W W 3. Energy Calculations
IN EXISTING OPENINGS OYes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPBNINGS-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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
JOB VALUATION $ %6�o OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion.Control
Park Fee
Sewer Main Charge
Total Due
$ �.00 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ j .001 times the total job valuation
$ 1 .0005 x Permit Valuation Minimum $5.00
$ C�OQ $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 PERMTT-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 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 pe,�` 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 + rk fhic u' •es review and approval of pl s. I _ F Q i
SIGNATURE OF APPLICANT RINT NAME �VI ��/ L(Jdli'1 1S DATE J'" "/ �I/
APPROVAL INSPECTOR SIGNATURE —T