P - 39334� ��� �S ✓
Building BUILDING Permit No.: �- �� I" �'
Inspections RESIDENTIAL APPLICATION Itecei�ect s�:
763-572-3604 CITY OF FRIDLEY Date R�:
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE v � I YOUR E-MAIL ADDRESS fYL I l til�
SITE ADDRESS S� o aK' �'C�(� (/� • ��
THIS APPLICANT IS: ❑ OWNE �ICONTRACTOR
PROPERTY OWNER/ NAME: ()'lrKe �lc�.rL d" C��1� LGt,t.c�L.4� / ^r �M� � �
TENAIVT ADDRESS: ��5� G�I�-� i N� CITY �Yi (��-�.-U� STATEV�//VZIP �J �J + c�Z�
PHONE: �� ,3 • �� y' � O�
CONTRACTOR NAME: C1me n�pr��^�°IT�:;e'��,
SUBMIT A COPY OF STATE LICENSE # o�c�3� u 3� LEAD CERT NUMBER N I� ����� �'� �
YOUR STATE LICENSE G�
AND CERTIFICATE OF ADDRESS: (j "Il7�i �� � CITY �� Cl� STATE�ZIP_�
INSURANCE pHONE �Ia��S,TS Z�C� FAX (� S�J'SZ g
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED WDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: NEW HOME CONSTRUCTION � ADDITION
MA[NTENANCE/REPAIR ❑ REMODEUNG
DESCRIBE WORK BEING DONE: `� r�.�� ti c,�ind.«.0 (1�, c�-1�{�' �:�. b r L'e ,
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ 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 ❑Softit ADDITIONS, & PORCHES SUBMIT:
� Aluminum ❑ Trim l. 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- SCRIBE 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:
��U�ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION S�t U 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
���Lf�
� �
��
��►SS'�`
See Back Page for F�e Schedule
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$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT1L PROCESSED
1 hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes City of Fridley and with the Minnesota Construction Codes; that 1 understand this is not a
permit but only an application for a per i and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of k whac re ire��view approval of pl s. /�/'/ //
SIGNATURE OF APPLICANT PRINT NAME ��/Vlri� %G�� I DATE ({� i `�
PLEASE NOTE: SEPARAT,� �EIilyjlTS ACf$ REQUIRTD FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK
1�