P - 84353Building BUILDING permit Ivo.: b a rbl,
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY I..
763-502-4977 FAX EFFECTIVE 1-1-2012 ��e������
DATE f C.� � eZ 3� � Z YOUR _E/-�MAIL ADDRESS e%i q 6L � aCC S i �/'Q �
SI'TE ADDRESS �'I � 9 IU ��n �b e 'r(:Ce
THIS APPLICANT IS: ❑ OWNER !�ON� TRACTOR
PROPERTY OWNER/ NAME: �
TENANT ADDRESS: ��� 9 .N Danc�h� �U CITY (� t� STATEmN ZIP 5SS/3 Z
PHONE:
CONTRACTOR NAME: Ir1 2 c n n1 Se r' S�(. c
SUBMIT A COPY OF STATE LICENSE #__ O�O L R o1- �� �— LEAD CERT NUMBER N,siT-a"��I �IS`T � EXp; y o�'Z '��cS
YOUR STATE LICENSE
ANDCERTIFICATEOF ADDRES5: 3�3 2 N`',�'1Y1tI��.�ti ��IY.°. CITY (MI�IS� STATE�NZIP �SYv(o
iNSURANCE PHONE �O I.2 -� Z i- S S a a FAX %�' Z Z- 3�!
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES E1C� ST� n �PBS1 dPlee'� ,
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK 1�6IDING ❑ OTHER
O SWIMMING POOL
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ ADDITION
J�4AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: R E Mv v a I � �t P I�C fv� ,cn �} a t S 1d �� n�,
SIZE OF IMPROVEMENT LENGTH WIDTH u HEIGHT S FT �
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
I. 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,
I�Vinyl �offit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim IiEMOVED? ,� YES ❑ NO l. Site Plan/Survey showing the existing structures
O Other � Fascia
and proposed project.
2. Two sets of construction plans
WINDOW 3. Energy Calculations
IN EXISTIN ENINGS �Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR ENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPE G CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED UN VALUA170N,1NCLUDIN(G THE COS"1' UN LABUK A1Vll MA7'ER1AL5:
(LTSING�HE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ oZ OCCUPANCY TYPE S u� ��t
Permit Fee $ �i ', j �� See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ �.001 times the total job valuation
Surcharge $ `+ I�" .0005 x Permit Valuation Minimum or .50
License Surcharge $ �,� $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2365 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ 8+ 6 ft= ft x$25= $
Erosion Controi $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ . � Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-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 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 wo�r w h re uires review and approval of plans. /
SIGNATURE OF APPLICANT �/ PRINT NAME �Ii 2 R.�JC�''1 E�9 ��/ DATE �0' Z 3 �� Z
APPROVAL INSPECTOR SIGNAT�