P - 44968Building BUILDING Permit No.:W{ � W
Inspections RESIDENTIAL APPLICATION Received By: r
763-572-3604 CITY OF FRIDLEY D ° °'���i �`�
763-502-4977 FAX `'��� �� �
EFFECTIVE 1-1-2011
DATE �y � / '� � � � � )YOUR E-�4IL ADDt2ESS �'� � � f QG� � �O �'z—�'
SITEADDRESS � � y' '���?"i �'��/ �� � r�/ c'� , � � ���,�
TH[S APPLICANT IS: e'OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: d<< ZS / �-
TENANT p,DDRESS: l�J L�ti /%� �CITY � STATF�% ZIP
PHONE: 7G c� �� 9�i�
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER
YOUR STATE LiCENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE pH NE FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT, TYPE ��DITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH O ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING � OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
G�MAINTEN CE/REPAIR ❑ REMODELI G
DESCRIBE WORK BEING DONE: /� C G� �°/ %�idNN��1 te ol. f%� � !y'r � C
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY . gASEMENT 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 HEIGHT.
SIDING FOR NEW CONSTRUCTiON fNCLUDiNG DECKS,
ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl �So�t l. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS es ONo LOCATION F WINDOWS L�,'�L ���k� WINDOWS – PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF S�saC J�`i �' ��J 7 MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & �
TYPE OF WMDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION. INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
oG�'HE 1997 U.B.0 FEE SCHEDULE)
OCCUPANCY
$ /([, 2 a' See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ 2�' .0005 x Permit Vatuation 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 Stioulations
THIS IS AN APPLICRTION FOR A PERMIT-NOT VALfD 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 Ivlinnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and�vork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all or hich � rev'ew and approval of plans. / / % /
SIGNATURE OF APPLICANT ,, , 1!�s���� PRINT NAME �dr� K/�L.$ //%//«- V� IATE � (� I C
APPROVAL INSPECTOR SIGNATU