Building Application 131223 Building Inspections BUILDING
Pe111:it No.:
76-3-572-3604 RESIDENTIAL APPLICATION Received By:
763-502-4977 FAX CITY OF FRIDLEY /
`` EFFECTR 7E 4115'13
DATE l _ ._�_ YOUR E-MAIL ADDRESS 4 _ M,6
SITE ADDRESS r
THIS APPLICANT IS: )eOWNER ,000NTRACTOR �.�� �l. 2 i 2f,,)1'3
PROPERTY O '"ER/ NAME:_ �-^ ,o _ _
�� l " ' L "' .
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TENANT ADDRESS: 01 61 - CITY .. Z1P
PHoNE-7tk3-414-L6755
CONTRACTOR
5UShSTT A COPY OF STATE LICENSE-' bbopplow LEAD CERT NUMBER ESP: 3
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: � CITY �STAT1 IP
INSURANCE PHONE .! 1 -5 FAX 3— W.-J()-60
PROPERTY TYPE SINGLE FAlviII.Y'i".MW CONSTRUCTION SIZE
rl MO FA!'�IMY NEW CO'dSTRUCTION STORIES
PEk&T TYPE ®ADDITION M GARAGE'S D Q)A7EV?OWS
0 BASEN ENT FINISH 0 ROOF 0 DRAIN TILE r
0 DECD U SIDING 0 OTHER
0 SVM4NENG POOL
TYPE OF WORK: W HOME CONSTRUCTION 0 ADDITION
E7 NMIIN�T�ENANCEIZEPAIR M RFNIODELr_\G
DESCRIBE WORK BEING DONE: C1 I W CIVV-e i I N"
SIZE OF INORO'Y'ENENT LENGTH X31 wmni R-f0" FEEIGHT r SQ FT
ROOFIN 0 HOUSE O"MY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES. 0 HOUSE&GARAGE 1. Existing Floor Plast
GARAGES �}, 0 ATTACHER GARAGE 2. Proposed floor plan
PROPOSED SIZE; DETACHED GARAGE 3. Liss of srrtsctural rud¢ttbe s to be assed
PRt)PC}SEDIIEIG}iT:
FOR NEW CONSTRti.:CTION INCLUDING DECKS,
S RV5G71 OSoffst SIDLVG/SOF•FITITASCIA. ADDIT 'NS &-2Q SST MI
C7 Aluanixruw C]Trim I \IO6'EI)? E3 1ES Cl !O 1. Site Plmistwrey&bowing the exssting structures
and proposed project.
0 Other 0 Fascia 2. Two sets of construction plans
WINISMA'S 3. EnerayCalculatious
IN EXISTING OPENIItiGS M es ®No LOCATION OF'IVINDOVi'S FOR WINDOW'S--PROVIDE UAIALUE AND
OF,FOR NEW OPENINGS-DESCRIBE SIZE OF MA.NLTJFACTLrRE STICKER ON 4VIV'DOW.
OPENING CHANGES& 11 1l�-
TYPE OF UT.NDOW TO BE INSTALLED ILYM N1)h1BER OF WTNDOu'S
ALL FEES ARE BASED ON VALUATION,INCLUDING THE COST OF 1ABOR ANDMATERIALS:
S \G T 9 ?'L.13.0 FEE SCHEDULE)
TOTAL JOB VALUATION$ Q va OCCUPANCY � TYPE
Permit Fee S See Back Page for Fee Schedule
Plan Review $ 65%of Building Permit Fee
Fire Surchartre $ .001 tinges the total job valuation
Surcharge S .0005 x Permit Valuation Minimum or.50
License Surcharge $ $5.00(State Licensed Residential Contractors)
SAC"Charge $ '$2435 per SAC"flint(Plans to NB VCC for deter ' a
Curb Cut Escrow $ ft+6 ft= ft x S26
Erosion Control S 5450 Conservation Plan Revie,%ar
Park Fee $ Fee Determined by Engineering
Sewer Main Charge S Agreement necessary( ) Non Necessary( )
Total Due $ M oke checks Ruble to: City of Fr tdley Attach Sti Mations
THIS IS AN APPLICATION FORA 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 l understand this is not a
permit but only art application for a permit and .work is not to start without a permit.on site, that the workwill be in accordance with the
approved plan in the case ofwork w i 1 r tlir s rew'iew and approval of plans. , �}
SIGNATL-RE OF APPLICANT PRINT NA2+,IE DATE '�``�j "'
APPROVAL INSPECTOR SIGNATURE
PLEASE dG1TI- SEPARATE PER: II S ARE F:E G'TF`ED TOR PLI ING,ELECTRICAL AND MECHANICAL WORK