P - 43884Building
Inspections
763-572-3604
763-502-4977 FAX
DATE /Q— I �_' `(
SITE ADDRESS �
THIS APPLICANT [S
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-1-2011
YOUR E-MAIL ADDRESS
V��C�
Q OWNER 1�dNTRACTOR
Permit No.: ��� � � "d �` �7�
Received By: -
���°��' l 4?� 11
PROPERTY OWNER/ NAME: QCn•'�o F6rhan�s Z 7�
TENANT ,qDDRESS: G�. % I ,c .'vti V.�C v �l �✓ CITY Fr. c✓%7 STATE �7ti ZIP !"r'Y*�J
PHONE: '�G 3- aa �- V f,,j" �-i;c�� ��G
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NArvtE:_%� � re.. I�e.»..a/.�... � ABA C/�.+.+c.1'c./ +,.-.o.�.,.. D..�.�
STATE LICENSE #�.O 6�,f' a/'I LEAD CERT NUMBER
ADDRESS: ?G� G�a.w�c�t .¢� S �"'�vv CITY_ lQ.��lL,s/� STATFiwtiZIPS�,%
PHONE �o �2 • 43 G 6- 1�
.B'SCNGLE FAMII,Y/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
❑ BASEMENT FMISH
❑ DECK
❑ NEW HOME CONSTRUCTION
�'1�1TENANCE/REPAIR
❑ GARAGE/SHED
❑ ROOF
❑ SIDING
❑ SWIMMING PO(
FAX
SIZE
STORIES
❑ ADDITION
O REMODELING
❑ DRAIN TILE
❑ OTHER
DESCRIBEWORKBEINGDONE: Ii. Z'�+PGi� �v�ra�•o�v SO.MG S��s
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE �. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HE[GHT:
IDIN
❑ Vinyl
❑ Aluminum
❑ Other
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS es ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENIIJG CHANGES & �/�
TYPE OF WINDOW TO BE INSTALLEDS"a ��+ ��`i�UIvIBER OF \
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
i. Site Pian/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $' GS� i� :�-ipTHE 1997 U.B.0 FEE SCHEDULE)
OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � 3 `1..��
$
$
$
$
$
$
$
$
$ i
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 pavable to: Citv of Fridlev Attach
THIS IS AN APPLIOATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 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 ptan in the case of all w ch requires review and approval; of plans.
SIGNATURE OF APPLICANT ����Rp��r-a,p�,L PRINT NAME_�L� /�r.c P c.� DATE �v ��Y-6/
APPROVAL INSPECTOR SIGNATU ' '