P - 48563Building BUILDING Permit No.�Olo2— L�-� � 3
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY Date Reo'd: � la—
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE � � Z, YOUR E-MAIL ADDRESS C R O W N R L U r F � C ll M G AS T• N��
SITE ADDRESS S 1� I �1 E S T i`� �a R E. L A K F_ D�. ( V�,
THIS APPLICANT IS: ❑ OWNER CONTRACTOR
PROPERTY OWNER/ NAME: T O M -S � 1� A F F
TENANT ADDRESS: CITY STATE ZIP
PHONE:
CONTRACTOR NAME: C R 0 w N 6� U h f- � iv -r � r� P R.1S G S I N G
SUBMIT A COPY OF STATE LICENSE # Q C '1 �'I 3 I�. O LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: I� I$� M I SS ! S S)�' P � �� 1 v �� N CITY �� A M P 1- ! N STATEI�II MZIP SS3 %�
INSURANCE pHONE S I Z- S K O" .3 �� FAX � 6
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDI1'ION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: O NEW HOME CONSTRUCTION � ADDITION
❑ MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �� ❑ HOUSE & GARAGE
I. 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 SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? 0 YES ❑ NO �• Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 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-DESCRIBE SIZE OF MANUFACNRE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL N'L�'L�'S AKI�; BASL�'ll UN VALUA"1'IUN, 1NCLUDING "THE CUST OF LABOR ANll MA"I'ERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surchazge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ 2-�—
$
$
$
$
$
ANCY TYPE
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum or .50
$5.00 (State Licensed Residential Contractors)
$2365 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 oavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID 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 Minnesota Conshuction Codes; that I understand this is not a
permit but only an application for a permit 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'(f� �' ' es 'ew and approval of plans. � t /
SIGNATURE OF APPLICANT 7�..1�` PRINT NAME QJ tav � t� �� L� u� ���^ DATE 3 I 7 /�
APPROVAL INSPECTOR SIGNAIURE M /1 �