P - 45215Building BUILDING Permit Ivo.: � �'��q'l
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY D
763-502-4977 FAX �� �'� 4 �
EFFECTIVE 1-1-2011
DATE J�� � YOUR E-MAIL ADDRESS
SITE ADDRESS CC � �'1'1GY�
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NqME: �/,�j�. ����;, �'
TENANT pDDRESS:� y� �/L'L L�/�'�`� � CITY �/l/,D L� �_STAT6r���Z'IA
PHONE: �,/�• — S '�j� �— „� 7,�
CONTRACTOR NqME: � �! �/ti ..�,��'�r�;��.�li �
SUBMIT A COPY OF STATE LICENSE # � LEAD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: ' CITY ����d��TAT�Zfi�����
INSURANCE PHONE FAX -- G>
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SiZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED �"LVINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BE1NG DONE: �r/��?�Cf�- /!1' �%I%��
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE L 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 INCLUDTNG DECKS,
❑ Vinyl ❑Soffit ADDITIONS & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing suuctures
and proposed project.
❑ Other ❑ Fascia 2. Two sets ofconstruction plans
WINDOWS � 3. Energy Calculations
IN EXISTING OPENINGS �KS'es ONo LOC�T ION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF /Si¢ C%� /� I� ���+5 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:
TOTAL JOB VALUATION $
Perenit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Controt
Park Fee
Sewer Main Charge
Totat Due
(USING T I�1997 U.B.0 FEE SCHEDULE)
� �C7d. OCCUPANCY
$ j{ 5, j� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ i .001 times the total job valuation
$ �` .0005 x Permit Valuation Minimum $5.00
$ ��D(� $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Pian Review
$ Fee Determined by Engineering
$�,�—�r—.,,�- Agreement necessary ( ) Non Necessary ( )
$ `''['d. /� Make checks uavable to: Citv of Fridlev 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 apptication for a permit and work is not to sta without a permit on site; that the work will be in accorclance with the
approved plan in the case of all ork which requires view an oval of plans. I
SIGNATURE OF APPLICANT iNT�ME ��� �(�, y�r � fOVi iP TDRTE ��=�
APPROVAL INSPECTOR SIG URE � � . /