P - 36774Building BUILDING Permit No.: �(�� j��i-1
Inspections RESIDENTIAL APPLICATION Received By: /�!��
�63-s�2-3604 CITY OF FRIDLEY n�.. ��a:: ��,� �, �� a
763-502-4977 FAX EFFECTIVE 1-1-2011 �LC"d �
na� ��' -
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STTE ADDRESS f 5��- ir CS.-��%��'��c`- ��
THIS APPLICANT IS: �OWNER ❑CONTRACTOR
PROPERTY O'WNER/ x,�; ' �,;�� � �, � �/✓
TENANT ADDRESS: /�;�w 7 �!'+-� ��yl`�r� �:l� CITY I'O ��I�1 � STATE n!/�ZIP �.J / c�Z
PHONE: � �`i � �°�-� �CQg�
CONTRACTOR N,�:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE Z�
INSURANCE pHONE FAX
PROPERTY TYPE Ji�SINGLE FAMILY/NEW CONSTRUCTION stz�
D �rwo F�n[,�tn�rEw coxs�rxucriox s�rolt�s
PERMIT TYPE 0�DITION f�t'GARACiE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF O DRAIN TTLE
❑ DECK �l9.SIDING O OTHER
O SWIMI�ZIIdG POOL
TYPE OF WORK: o r�w xo� caxsTxucriox ❑ AADITION
❑ MAINTENANCFJR�PAIR ❑ REMODELING
DESCRBE WORK BEING DONE: I� ���' �i,� S/t���
SIZE OF IIKPROVEMENT LENGTH WIDTH HEIGHT FT
❑ HOUSE ONLY BASEMENT RE
N�LIMBER OF SQUARES � '� HOUSE & GARAGE �'d.�DELiNG S[J$MIT:
1. Existing Floor Plan
� O ATTACI�D GARAGE 2. Proposad flo� plan
PROPOSED SIZE: 0 DETACf�D GARAGB 3. List of structural members W bo usod
PROPOSED I-�IGHT:
FOR NEW CONSTRUCT'ION INCLUDING DECKS,
O�V'm�yl� � � C7Soffit �j?DITIONS_ � PORCHE$ ��MIT:
� Aluminum ��, Q �� l7 Trim 1. Site Plen/Sutvey ahmying the eacisting stiuchmes
� Other �I � ❑ Fascia �d p� P�Oj�'
2. Two sets of consWctIon plans
WII�iDUWS ` 3. Energy Calculatia�a
IN EXISTWG OP S �Yes ONo LOCAT'ION OF WlNDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPBNINGS-DESCRIBE SIZE OF MANUFAGTURE STICKER ON WINDOW.
OPENING CHANGES Ft
TYPE OF WINDOW TO BE 1NSTALLED Nt3MBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION. INCLUDING TI� COST OF LABOR AND MATERIALS:
v.
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota1 Due
(US1NG THE 1997 U.B.0 FEE SCI�DULE)
See Back Page for Fee Schedule
65% of Building Pern►it 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 uavable to: Citv of Fridlev Attnch
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
pennit 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 �a1,,�1��� revi pproval of p /� I/ O
SIGNATURE OF APPLICANT ,��/ e PRINT NAME �iJ f�r� ���F f'�. DATE c7 �1 ��' l�