P - 36672Building BUILDING PermitNo. �"�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY nate • r, �
763-502-4977 FAX EFFECTIVE 1-1-2011 ��-�����
DATE �� '�S �� G'/� YOUR E-MAIL ADDRESS
SITE ADDRESS '�/3� %f I��KUit7,�l 7��yz�-�
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: �.irl �' A%An/�Jl� �Li�Dc�..l
TENANT ,qDDRESS: �7/3% /C/C1E.Yi/i�"� % L�•C�fC'�`CITY �,�.'/Di[.F"�/ STATE�ZIP ��y3a
PHONE:_%� 3 �S�s D '7%D
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: J� �� �� � T� G,aN� ��• CITY /fA1�'/ L-N�-'� STAT�II ZIP J��
PHONE
SiNGLE FAMILY/NEW CONSTRUCTION
TWO FAMILYMEW CONSTRUCTION
❑ ADDITION
❑ BASEMENT FINISH
❑ DECK
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION
.. � R�MAiNTFNAU('F/RFPAIR
FAX
SIZE
STORIES
�jtOOF ❑ DRAIN TiLE
❑ SiDING ❑ OTHER
❑ SWIMMING POOL
❑ ADDITION
❑ REMODELING
DESCRIBE WORK BEING DONE: �E12Gd� Gh1 ,�'J/Z/t'IE%Z Ka�F
SIZE OF IMPROVEMENT I T LENGTH ��T WIDTH HEtGHT /aT��%� I�'g p'�'
ROOFING �FiOUSE ONLY
NUMBER OF SQUARES APPR�X. �St ,S ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
L- 1. Existing Floor Plan
GARAGES � ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural membersto be wsed
PROPOSED HEIGHT:
' SIDING
; ❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENMGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENWG CHANGES &
TYPE OF WINDOW TO BE INSTALLED
❑Soffit
❑ Trim
O Fascia
LOCATION OF WINDOWS
NUMBER OF
FOR NEW CONSTRUCTION lNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calcutations
FOR WINDOWS - PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
_ . - -
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
/�/�� ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ (dW� OCCUPANCY TYPE
Pertnit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$ �(S
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the tota) 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 APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCE3SED
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 f a perm' 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 al ork which equires eview and approval of plan
SLGNATURE OF APPLTC PRINT NAME �C'l�I% �i���L�!'/� DATE �- /.S'v?c'J/�