P - 46290Building BUILDING Permit No.• d
Inspections RESIDENTIAL APPLICATION Re�ei�ect By:
763-572-3604 CITY OF FRIDLEY Date�� �'�'I� ;� �' �
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE �; •._/'? -/ r YOUR E-MAIL ADDRESS
SITE ADDRESS ���, Tf (',Z_/`��C �rA1/ �C�.'
THIS APPLICANT IS: ❑ OWNER � ONTRACTOR
PROPERTY OWNER/ NAME: L
TENANT ADDRE S: Cpt ��' CzZ�'t iX.b'�l/ CITY ��iG�,�/' STATE�IP g,�i�I -
PHONE:C'�Co3 ) '� S�I-���'09 •
CONTRACTOR NAME: I��k,ygt� µ 1.�
SUBMIT A COPY OF ^L� t 1S/�� LEAD CERT NUMBER
YOUR STATE LICENSE STATE LICENSE #��-,
AND CERTIFICATE OF ADDRESS: CITY STATE�IP�.
INSURANCE PHONE STi/ r- FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION D GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OF O DRAIN TILE
❑ DECK S[DING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: O NEW HOME CONSTRUCTION D ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �,1--�ZlJC�-
SIZE OF IMPROVEMENT LENGTH WIDTH HE[GHT S FT
RO 1 ❑ HOUSE ONLY
NUMBER OF SQUARES � ❑ HOUSE & GARAGE �ASEMENT REMODELING SUBMIT:
1. Exisdng Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of sauctura► members W 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 �d proposed project.
2. Two sets of consqvction plans
�y�pp�yg 3. Energy Calculations
IN EXISTING OPENINGS OYes ❑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 INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUA`1'IUN, 1N(:LUD1N(i 7'riL�' CUJ7' Ur' LABUIt A1VU MA�1�L�;K1AL.�':
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Controt
Park Fee
Sewer Main Charge
Total Due
$ 4['�l�S See Back Pa�e 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 ( )
$ / A, Make checks pavable 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 o 11 0 �'c � uires review and approval of
SIGNATURE OF APPLICANT _ PRINT NAME 2 DATE
APPROVAL INSPECTOR SIG A RE ___