P - 48526Building BUILDING perrriit No.
Inspec?�ions
763-572-3604
763-�02-4977 FAX
DATE `T - /1 �' '�
SITE ADDRESS /y�Y
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
!/�C LrY�
Received By:_
D����°�+:R�
YOURE-MAILADDRESS �l'I�G �LJC� �i �� �1.��L? ��^�^�r�`�✓�y I'E ✓✓t�*e��-���tc�.Cc!✓�
T—
A�. �.
�� THIS APPLICANT IS: ❑ OWNER LidCONTRACTOR
PROPERTY OWNER/ N,a�v�E: �j�, /�.�. 3
, ya2�!%SS�� t-l��.eti
TENANT qDDRESS: /�{ �`I `� LL�� i�a�r rne'r'c� ('�'rz
PHONE: � I Z' �j�el ' �' Z `�J((P
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
STATE �✓t ZIP �JS� 4�2�
NAME: � r� C Ir�%f.t. �f AI� c.{. Ccv:� �r�/ l��F'v�tCt�e.�t�"� +.�
STATE LICENSE # � L j(p 3 3 C> LEAD CERT NUMBER
ADDRESS: ���%�� l�vi �`ry i2.� C�� ��' CITY �1 �� C V76� STATE t$�M ZIP -rj S 3��,
PHO E (r.% ( Z` ZC' Z- (c�Zl 2- FAX
SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ �O FAMILY/NEW CONSTRUCTION STORIES
ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAfN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING P OL
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
I�ESCRIBE WORK BEING DONF..:
SIZE OF iMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED
c r1 l.t�c ✓° c
H
ADDITION
❑ REMODELING
/t C�c�, -�f d .1
� WTDTH
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
NUMBER OF WINDOWS
3��� ' HEIGHT �3 � SQ FT � 3�
BASEMENT REMODELING SUBMIT:
I. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS, & PORCHES SUBMIT:
l. 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 O.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ Z�% , � ��c • 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
$ ' �� � 1j
$ .� C"� r i ��
$ ��°1, ��
$ f?; t��_? "',
$
$
$
$
$
$ `'� � . �� C.; s
See Back Page for Fee Schedule
65% of Building Pennit 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 Pian Review
Fee Determined by Engineering
Agreeinent necessary ( ) Non Necessary ( )
Make checks pavable to: Citv of Fridlev Attach
ulatinnc
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 Construction Codes; that I understand this is not a
permit but only an application for a mit a, 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 all � e review and approval of plans.
r
SlGNATURE OF :APPLICANT l��� .� '` PR1NT NAME C✓ �� ��'« 1� DATE ��� Z�' ` I�
� 3
APPROVAL [NSPECTOR SIGNATURE , �"`':y �t � L /`�-;
�
3OHN J. RYA�' CO.
� 7�95 SELBY AVEi�JUE, ST. PAUL 55!04
:�s
SCALE: 1 1NCH__ _�'�__—_— _FEET TELEPHO�lE: 6",o"-5c5E
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