P - 62716BUIIC�IT"lg BUII.�IN(i Pennit No.:�iZ�L��,7 ��j�
Inspections RESIDENTIAL APPLICATION Re�ei�ed By: �(�
763-572-3604 CITY OF FRIDLEY Da 'd Y �C�1
763-502-4977 FAX �� � � � �
EFFECTNE 1-]-2011
DATF � J �� YOUR E-MAIL ADDRESS ' '` �� ^. . . �;�'N
Sl'l�E ADDRGSS l��il.r_5 ��j(�`?X? t��+ �,�j�
THIS APPLICAN"1' [S: ❑ OWNER I�ONTRACTOR
PROPERTY OWNER/ NqME: � ' ,��
TENANT ADDRESS: ^` CITY STATE ZIP ��{, •�'
PHONE:� �(y� ) `1 �l"' � 1�Z
CONTRACTOR NAML-: �I0. RtlO�r+t1q � �.rnc,ckll.\erra
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSL- #��� LEAD CERT NUMI3ER ��- a5o3y— �
AND CERTIFICATE OF ADDRLSS: y�4� �yfCl,1$It?':� T3�\JC� CITY�.�Ot�.is �ia+M1t, STATG� ZIP�S�jiV�G
INSURANCE p�iONE q5%1 ^ Ci t5 �'°7'1�„ F�x qe �- q�a - yy
PROPERTY TYPE �S[NGLE FAM]LY/NEW CONSTRUCTION SIZE
❑ TWU FAMILY/1VE\�/ CONSTRUCTION STORIG �
PERMIT ��YPG � ADDITION ❑ GARAGE/SHLD INDOWS
❑ BASEMENT FINISI-1 �`ROOF ❑ DRAIN TILL
❑ DECK ❑ SIDING ❑ O"iliER
❑ SW[MM]1��G POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTIO;V ❑ ADDI'CfON
� MAINTENANCL/REPAI, REMODELN � .� �
DESCRIBE WORK BEING DONE: � ` ��} "; `?''� � �� n ' ' �� ^
SIZG OF IMPROV6MENT LGNGTH ___ WIDTH HEIGHT SQ FT
ROOFINC ❑ HOUSE ONLY BASEMENT RLMODELING SUBMIT:
NUMQER OP SQUARES �L__ �HOUSE & GARAGE L Lxisting Floor Plan
GAR.4GES ❑ ATTACHED GARAGE 2. Proposed tloor plan
PROPOSED SIZ�: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSIiD HLIGI�IT:
SIDING FOR NEW CONSTRUCTION INCLUDWG DGCKS,
❑ Vin I ADDfCIONS. & PORCHES SLIBMIT�
Y ❑Soffit (, Site Plan/Survey showing the existing structwes
❑ Alwninum � � ❑ 1'rim
❑ Other � -. (�•, � ❑ Fascia and proposed project.
��;v 2. Two sets of construction plans
WII�DO�VS 3. LnergyCalculations
IN EXISTING OPGNINGS ❑Yes ❑No LOCATION OF WIh'DOV�JS FOR WINDOWS —PROVIDG U-VALUE AND
OR FOR N���' OPFNINGS-DF.,SCRIBC- SIZE OP MANUFACTURE STICKER ON WINDOW.
OPI:\'ING CFIAVGES &
I�YPL OF WINDOW TO 13E INSTALLED VUMBER OF W[NDOWS
ALL FEES ARE [3ASED ON VALUATION, INCLUDINC THE COST OF LABOR AND MATERIALS:
(USING THE ]997 U.B.0 �EE SCHEDULE)
TOTAL JOB VALUATION $ _ OCCUPANCY TYPE
Permit Fee
Plan Rcview
Fire Surcharge
Surcharge
License S�n-charge
SAC Charge
Curb Cut Escrow
Erosion Control
Parl< Fee
Sewer Main Charge
Total Due
� � 5 '� ��5
�
$ ��J�
$
� ,� U�..
$
�
$
$
S
� l i �� , , �,,�.
See Baci< 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 Licei�sed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
�450 Conservation Plan Review
Fee Determined by Engineering
Agreement neeessary ( ) Non Necessary (
Make checks pavable to: Citv of' Fridlev
Attach Stipulations
TH1S IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCGSSGD
I hereby apply for a building �ennit and I aclaiowledge that the infon�ztion above is complete and accurate; that the work will be in
confonnance with the ordinances and codes of the City of Fridley and with the Minnesota Coi�shuction Codes; that I understand this is not a
penrit but only ai� application gpe � d w 1� not to start without a permit oi� site; that the work will be in accordance with the
approved plan in the case of al w_ _„� w and approval of p�,an �„ (� �y
SIGNATURE OF APPL]CANT ���"',c�'�,� PRINT NAME ������t � j�, �;,,�O�;� ° DATE !,a I C�
APPROVAL INSPLCTOR SI
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK