P - 46545S� `-9
Building BUILDING permit Ivo.: U
Inspections RESIDENTIAL APPLICATION xeceive� '
'��a3-572-3604 CITY OF FRIDLEY vate Re�'�t� °`�' �
a�13-SO�-49%% FAX EFFECTNE 1-]-2011
DfiTE YOURE-Iv1AILADDRESS ml�C�.l�iC�riti4vt.�tt�:YuaPd�E.rJ t.L�ite�l�-S mfL C 6v�
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Tf�15 APPLICANT IS: ❑ OWNER �CONTRACTOR
PRUP�RTY OWNER/ NAME:��Y���'yi.l Cl���-
TENANT �D�ss:SYD3 Gc3 �2�r/� ,�'ass ci'rY�r�'c���u STATF��ZIF��_
PHONE: � � ��� '7�3 -S 7y -D93 /
CONTRACTOR NAME:
SUBP✓IIT A COPY OF STATE LICENSE # e�Q il�a c� �.� LEAD CERT NUMBER �1»r �3� i� �
Y�UR STATE LICENSE ;L` ,r�
?.ND CERTIFICt1TE OF ADDRESS: ��� �Jt? `S'� CITY ��� /v'�,t� STATE�ZIP SSro�
INSURANCE PHONE DS"� FAX
PitO�ERTY TYPE �,SINGLE FAMII.Y/NEW eONSTRUCTION SIZE
❑ TWO FAMII�Y/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ arDiTTON ❑ ��cF✓s�D �ows
❑ BASEMENT FIIdISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDTI'ION
NANCE/REPAIR ❑ REMODELING
DES��RIBE WORK BEING DONE:��. � W j�sQQ�S
SI�.E OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
$Ot7FITG ❑ HOUSE ONLY
NUI�iBER OF SQUARES ❑ HOUSE & GARAGE �ASEMENT REMODELING SUBMIT:
1. Existing Ftoor Plan
G�iR'AGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: 0 DETACHED GARAGE 3. List of structural members W be usel
PROPOSED HEIGHT:
��G FOR NEW CONSTRUCTION INCLUDING �ECKS,
ADDIT'IONS_ & PORCfiES SUBIVLiT
O'�'�yl ❑Soffit 1. Site Plan/Survey showing the existirg structures
❑ A.:uminum ❑ Trim and proposed project.
❑ C�zher ❑ Fascia 2. Two sets of construcrionplans
WIIh-D�O�JVS 3. Energy Calculations
IN EXISTING OPENINGS '�Yes ONo LOGATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALITE AND
C�F_ FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
C�FE'VENG CHANGES &
TYP� OF WINDOW TO BE INSTALLED NUMBE� OF WINDOWS
[ii,i, rr,�a Axr, isa�r,L Vlv vALUA 11VPI,11vC;LULIiVI� lHr; C:V�l Ur' LAKVK A1Vll MA'1'L�'K1AL�:
COTAL JOB VALUATION $�, 9SS�' ING THE 1997 U.B.0 FEE SCHO CUPANCY TYPE
Fera�it �Fee
Fl�n Review
Fi~e Surcharge
S�ur�harge
Li:,ense Surcharge
S�liC Charge
Cur� Cut Escrow
Eresion Control
P� Fee
Sev�er Main Charge
'I'ot�l Uue
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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 APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I h�reby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work wili be in
c�=ormance with the ordinances e the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio p d ork is not to start without a permit on site; that the work will be in accordancF with the
ap�roved plan in the case of ire iew and approval of pl '/ �� �
SIGP7ATEJRE OF APPLICANT PRINT NAME��i� ,E,LJ�,`���� DATE � 3 �(
A.FPROVAL INSPECTOR SIGN
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