P - 46550Building ' BUILDING Permit No.: � I I�o� Sa
Inspections RESIDENTIAL APPLICATION Receiv �
763-572-3604 CITY OF FRIDLEY Date Re
763-502-4977 FAX � EFFECTNE 1-]-2011
DATE �� � 5 �� YOUR E-MAIL ADDRESS d C.0 C, ! C� �vi SP�1 Lr OO �' 1�q . C b rr.
SITE ADDRESS S�oO�a ���5 T�0.t,
THIS APPLICANT IS: ❑ OWNER 0�3�',ONTRACTOR
PROPERTY OWNER/ NAME: ar� 22 � 4� �yl
TENANT ADDRESS: ��3 � eQ IS` � a�� CITY r i d 1�e.,.� STATE nZIP s a`[ 3�.
PHONE:�S ( " � q Z ' �i3 G
CONTRACTOR NAME: .l�IR RtlOE+tllq i '�R�t.moc,�.�i�nn
SUBMIT A COPY OF '�C�('� LEAD CERT NUMBER N�- a5o3y- �
YOUR STATE LICENSE STATE uCENSE # �"
AND CERTIFICATE OF ADDRESS: y:� �Cf.LSid'r T��VC� CITY'�.�Ottts �wt. STATE� ZIP�SV<<i
INSURANCE PHONE q5� -�'11'S ``7? FAX C{6? - 4� 1-
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAM[LY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �'[tOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER �
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOMECONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: tf' '4'
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �� ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES O ATTACHED GARAGE 2. Proposed floor ptan
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 1• Site Plan/Survey showing the existing structures
O Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. EnergyCalculations
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 [NSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASEll ON VALUA'17U1V, 11VCLUUIIVG �I H� 1:U57' UH' LAIfVK A1VU 1V1A7 EKIALJ:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surcharge $ �jb $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$24 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ � 3 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
approved plan in the case of all ork which require/�}��jvieyv� nd approval of pla (
SIGNATURE OF APPLICANT p�,�d'iY�-rt- U JGf.�ii� PRINT NAME ��nnc` U I% CK DATE � � I I S I � �
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK