P - 47278Building BUILDING Permit No.: ����� �
Inspections RESIDENTIAL APPLICATION Received By: ��
763-572-3604
763-502-4977 FAX CITY OF FRIDLEY vate xec'd: � f/
EFFECTIVE 1-1-2011
DATE I�� 3' � I YOUR E-MAIL ADDRESS �-(�C�� ci� J?�CXi j'��+..Qa:N�cQ� ,Cpf��
SITEADDRESS �%� O`fa�r� ��� {V�'e,
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: � ^k��,.��a�
TENANT ADDRESS: �9ay W"4� *G�na► �C�a+� CITY YY1�Il� STATLM�V ZIP ��
PHONE:�p�,� .. '���+Qroto�
� CONTRACTOR NAME: �3 P�boe,�. St�c'v\ci.�
SUBMIT A COPY OF STATE LICENSE # '�3"�� O �Si$d LEAD CERT NUMBERN �'— �6953^��
�Ypi�R STATE LICENSE
,..AND CERTIFICATE OF ADDRESS: 'ei,j�ie�lp �se�:i. a CITY C�p�b.,•-� STATE(�1ZIP �3Yo
' ' INSURANCE PHONE (��oi•S/o'�'�d � FAX
;(PR��ERTY' TYPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE
- _ ❑ TWO FAMILY/NEW CONSTRUCTION STORIES
�,,� PERMIT TYPE ❑ aDDiTiorr ❑ GaRaGEisxED m.wirrDOws
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �REMODELING
DESCRIBE WORK BEING DONE: � �' I�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
1. Existing Floor Plan
�ARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PRO 0 SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SITSI�� '` FOR NEW CONSTRUCTION INCLUDING DECKS,
fl Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
O Al��inum a ❑ Trim 1. 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 30 st�i3 t.�}.it�) MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED O�.'�.� NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�I�� OCCUPANCY TYPE
Permit Fee
�'la�i- Review
��re, Surcharge
����.h�rge �
�,ic�rise Surcharge
�AC Charge
�ilrb `Cut Escrow
�fosion Control
�'ark Fee
Sewer Main Charge
$
$ � �'�
$ „ �U
$ � �x�
$
$
$
$
$
$ l�_.�3 �
See Back Page for Fee 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
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
appr'o�ed plan in the case of al� �vork w' equires review and approval of pl s.
�IG'rNATUREOF APPLICANT °�"�i PRINTNAME a�Z��x��c.�'� DATE � �— I- �)
�A,�P�tpYAL INSPECTOR SIGNA RE
+.�._ ...,, PLEASE NOTE': SEPARATE ' ARE REOUIRED FOR PLUMBING, ELECTRICAL AND ME�HANICAL WORK
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