P - 45763Building BUILDING Permit Na�� ����
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY va 'd: ��
763-502-4977 FAX EFFECTIVE 1-1-2011 � "�'' >
DATE (D YOUR E-MAIL ADDRESS .,,.] ��� 1 ���C�f " �X�CiI (7iS 1%t/� � �LJ/1'l
SITE ADDRESS % �� I Id�Y)��TL�% �1%L� /V��
THIS APPLICANT IS: ' ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: t1' i�'li C.. /LIQ%�c-�� A�
TENANT ADDRESS: �J/'�Y'✓�C /�I"S �T� CITY STATE ZIP
PHONE: �G ,�j -- S�°f —����
CONTRACTOR NAME: ����"C,� E��-�1G1� 2� �� F t/l/ AI
SUBMIT A COPY OF STATE LICENSE #�Ca 3S�- ,�f9 LEAD CERT NUMBER % �3 T 3' �
YOUR STATE LICENSE ���
AND CERTIFICATE OF ADDRESS: S%G �'/N � S�' CITY/�:.d`�'�l.:cZ� STATE /kA�ZIP SS36 ,.2
INSURANCE pHONE 7�O �-- 'Z I"" FAX Z � I��
PROPERTY TYPE INGLE FA /NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCE/REPAIR MODELING
DESCRIBE WORK BEING DONE: �O F r Nis- ��-�'—P�-f�C�' /I'1_�b' E
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �"� �OUSE & GARAGE 1. Existing Floor Plan
GARAGES �1"TACHED 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 ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim r. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION 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 BASEll UN VALUATIUN,INCLUll1N(G "1'H� CU5"[' UN' LABUK A1Vll MA"1'1;1t1ALS:
,� (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
��i��y
� 0►"�'ZS See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ �j $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 ( )
$ [fi n� Make checks �avable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN'fIL 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 o r ich r ires review and approval of plans.
SIGNATURE OF APPLICANT �� "�— PRINT NAME �GiF� `o �-C�NLn/ i'�J DATE ��//
APPROVAL INSPECTOR SIGN�