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Building BUILDING Permit No.:^O ' � �
Inspections RESIDENTIAL APPLICATION Received By:.
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX EFFECTIVE 1-1-2011 ��e��
DATE p � � ( �..cc��.. YOUR E-MAI ADDRESS � � �v� Y 1� ( � �� �`� I n C - ���
SITE ADDRESS �� �/ Gl(1 �Ci�,i� . U�/ �'
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: Q�,Q ` `�"� G�-��'7
TENANT ADDRESS: � p . � � CITY � STATE�LZIP�-��a
PHONE: ( � �
CONTRACTOR ' +"`'
NAME: 1
SUBMIT A COPY OF STATE LICENSE #� V��)� �� � 1'7 �"��' � CJ �~ I
YOUR STATE LICENSE ' LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: aQ�'i � nt�hcryv� Ln • � � L5 CITY STATE�ZIPs�`r� � n
INSURANCE p ONE C� '" FAX C9� ���J 'rS a'
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMTT TYPE ❑ ADDITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBEWORKBEINGDONE: QOC�-L� �/�. (�L��UI�) �?�-�!''�[5 - �./�%'LP ��� .
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. 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 INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia
and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-b�SCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & �
TYPE OF WINDOW TO BE INSTALLED NLJMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION. INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALOATTON $ I C� OCCUPANCY TYPE
Permit Fee $ C� ' See Back Page for Fee Schedule '�
Plan Review $ � 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ i .0005 x Permit Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft + 6 ft = ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Deternuned by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ � Make checks payable to: City of Fridley Attach
THIS TS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby apply for a building pei�n�t, and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and c es o e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a pe 't nd work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of r re 'res revi an proval of p1�rJ�s; _ � �� t��T-
SIGNATURE OF APPLICANT INT NAME I Y I.UI�'r +� i LF� �� DaTE o
APPROVAL INSPECTOR SIGNATUR _ __