P - 45272Building BUILDING Permit No.: �6 I l'�U� ��
Inspections RESIDENTIAL APPLICATION Received By: i� i�
763-572-3604 CITY OF FRIDLEY Date �� ��� ����
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE_ ;=�T ��`'� / YOUR E-MAIL ADDRESS J ��-• � L�7"�r«.� c�,`• �c: ;�, Cc,� �
SITE ADDRESS �; � =y L.� (.✓. `t �;1� ; � , <,r �<' � C'•f
THIS APPLICANT IS: ❑ OWNER c;'�CONTRACTOR
PROPERTY OWNER/ N�tE: .�,�,- ..�� ,
� ��c ��
TENANT '
ADDRESS: C.° -=>S�-? i,/.� < F ,.,�.�. ., �f CITY ��� , �'l�� y STATE�`�N ZIP
G, .
CONTRACTOR NAME: L�,� z, Gc,.� str�
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SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE #�� aC� LEAD CERT NLJMBER
AND CERTIFICATE OF ADDRESS: `'�U�i ./�� w, �.� �c�,.0 CITY ���j; /� STATE�IP `iS�-r� /
INSURANCE PHONE J/�'s - L�� ��- �"?>Gi S FAX
PROPERTY TYPE
PERMIT TYPE
SINGLE FAMILY/t�IEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ ADDITION ❑ GARAGE/SHED
❑ BASEMENT FINISH f�'ROOF
❑ DECK � SIDING
❑ SWIMM►NG POOL
SIZE
STORIES
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR REMODELING
DESCRIBE WORK BEING DONE: t' '/`!� r��'
SIZE OF IMPROVEMENT c�. �. ,�-G LENGTH WIDTH
ROOFING �� ❑ HOUSE ONLY
NUMBER OF SQUARES �HOUSE & GARAGE
GARAGES
PROPOSED SIZE:
PROPOSED HE[GHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
'� WINDOWS
li IN EXISTING OPENINGS ❑Yes ❑No
� OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
�' TYPE OF WINDOW TO BE INSTALLED
�tl ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
HEIGHT
FT
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of struc!ural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
t. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ w'j ��LS See Back Page for Fee Schedule
$ ' 65% of Building Per►nit Fee
$ .00I times the total job valuation
$ � .0005 x Permit Valuation Minimum $5.00
$ 6 $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 VAL1D 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 Construction 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 of al� v�or �which requires review and approval of plans.
SIGNATURE OF APPLICAN�=%'s%6� PRINT NAME �� G•7�i ,•` DATE �v/�//
APPROVAL INSPECTOR S