P - 46507Building BUILDING Permit No.: � �5 �
Inspections RESIDENTIAL APPLICATION xeceived sy:
763-572-3604
763-502-4977 FAX CITY OF FRIDLEY Date Rec'd: ��--�1�_
EFFECTIVE I-1-2011
DATE I�' � l� /� YOUR E-MAIL ADDRESS
SITE ADDRESS � L' i � � L-'�- �t'-e-1� ��/Y'�r C��
THIS APPLICANT IS: ❑ OWNER �1CONTRACTOR
PROPERTY OWNER/ N,�: ��'� L�hV e
TENANT ADDRESS: CITY STATE ZIP
PHONE: l� ��. �•�� O.- (� � U.�
CONTRACTOR NAME: ! Ov�i� qOr`ii � c,.
SUBMIT A COPY OF STATE LICENSE # �' G.�o LEAD CERT NUMBER /r ���G�- S�'�'-I
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS:���'�G a�illc+�`� .;�f'. N� CITY��y L�f��- STATF�t/1,ZIP��
INSLIRANCE PHONE - '°� ^ , �e.'-Z' FAX ��.� " �✓ / — � c:5`
PROPERTY TYPE r� SnvGt,E F�LY StZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ nDniTION ❑ Gn�GE/S�n ❑ wlrrnows
❑ BASEMENT FIN1SH �1'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
`� MAINTENANCE✓REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � �"'- G� �/^�? .
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF S UARES � �� BASEMENT REMODELING SUBMIT:
Q 'F�'HOUSE & GARAGE �� 1. Existing Floor Plan
GARAG�S $ 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 ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ 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 OPENIAIGS ❑Yes ONo 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 INSTALLED NLJMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE CO5T OF LABOR AND MATERIALS:
SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�1-- �_� _ . _ _ _ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
� 111 � G� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
�� .001 times the total job valuation
$ .O .0005 x Permit Valuation Minimum $5.00
$ j� ' $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 ( )
a 1 d-,L .� Make checks pavable to: Citv of Fridlev Attae
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appty 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 Nlinnesota 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 wark will be in accordance with the
approved plan in the case of all w rk wh,,i,ch�'equires review and approval of plans. ,*
SIGNAI'[JRE OF APPLICANT �� ,.�e%�!-� PRINT NAME ,�'��7n ���d / J �e.' DATE ��'� � ��
APPROVAL INSPECTOR SIGNATURE
PLEASE NOT'E: SEPARATE PERMiTS ARF. RF.f3I TiRF.T� FnR AT.i IMRiNf� Fr,�.rTRrra7. n�tn r�nuea.nrrer wnuTr