P - 45202Building BUILDING Permit No.: � -C?�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'ct: � �
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE ! � I YOUR E-MAIL ADDRESS
SITGADDRESS �a��7 �QY' 3h (1'� �v�-�
THIS APPLICANT IS: ❑ OWNER �iGONTRACTOR
PROPERTY OWNER/ NqME:
TENANT pDDx�ss: la Or�a �'rY �i"t ��2u STaT
xE 1/l ZIP 5s .3s.
PHONE: �01.2 ` %I � `� o�. 1%S i
CONTRACTOR NAME: ✓C10. Rc�O�ttq C "R�.moc�.t.\tc�
SUBMIT A COPY OF STATE LICENSE # IO,�71J LEAD CERT NUMBER N�- a5o3y" �
YOUR STATE LICENSE c-.
AND CERTIFICATE OF ADDRESS: L::�� G..xGtlSid'r C��Ut� CITY'Ji�.�OULS �i.M�. STATE� ZIPSsVI�il
INSURANCE pHON6 q5Z-G�s�'7�,� FAX CL6'1 - �ta� —
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �E3'200F ❑ DRAIN TILE
❑ DECK ❑ SIDfNG O OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �
SIZE OF IMPROVEMENT LENGTH WIDTH IGHT SQ FT
ROOFING �/'') ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES c/�� ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZL: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Atuminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Caiculations
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 OP WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997�.tU.B.Cr F�EE SCHEDULE)
TOTAL JOB VALUAT[ON $ �'J, { �i � � � `-tl �a (G' 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
$ J//, a� See Back Page for Fee Schedule
$ T" 65% of Building Permit Fee
$ � .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ i� Make checks aavable to: Citv of Fridlev Attach Stinulations
THIS [S AN APPLICA
I hereby apply for a buildi��g permit and T aclmowle<
conformance with the ordinances and codes of the ity
permit but only an application for a permit and wo k'
approved plan in the case of 1 work which �eA 're
SIGNATURE OF APPLICANT V
APPROVAL INSPBCTOR SIGNATURE
PLEASE NOTE: SEPARATE PERMITS AT�� b
R A PERMIT-NOT VALID UNTIL PROCESSED
th t the information above is complete and accurate; that the work will be in
dley and with the Minnesota Construction Codes; that I understand this is not a
t to start without a permit on site; that the work will be in accordance with the
�and pproval of pla s. �
�N7'N�eIG�E L�y,� ���G� DATE 7/���/
ELECTRICAL AND MECHANICAL WORK
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