P - 42738Building
Inspections
763-572-3604
763-502-4977 FAX
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BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
F.FFECTTVE 7-1-2010 _
SITE ADDRESS !// � � � � �y
THIS APPLIGANT IS: ❑ OWNER
PROPERTY OWNER/ N�: /"-��✓,I/
TENANT �D�ss: _
PHONE:
YOUR E-MAIL ADDRESS
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Pernut No.. --.
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CONTRACTOR N�: �/c'74�"f �2 ��R=�-7 � rAi�� t?✓J�h.h�T'���''� e-�- � -—
SUBM[T A COPY OF STATE LICENSE #,(X_.� -�` -2� y��'�I Z EXP DATE ���/ � � Z
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �a �'X y9�y�' CITY ,c�'G�-rf-1r��` STATiwt��LIP �-S"�'� '
INSURANCE PHONE � /� �- �P ia � ' C? � 3�� FAX ��P � `" %� � �- S� 3 �Z
PROPERTY TYPE ❑ s�rGLE Fa�.Y�rrEw corrs�rxucTTOx slzE__
p TWO FAMII,YtNEW C'ONSTRUCT'ION STORIES
PERMIT TYPE ❑ ADDITION u u�����r.i�n�L �•U�- �•.�
❑ BASEMENT FIDiISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING �OTHER
❑ SWIMNIING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION C7 ADDITION
hZMAiNi'FNANC'.F.lRF.PATR ❑ REMODELING
DESCRIBB WORK BEING DONE:
SIZE OF IMPROVEMENT _
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'�rb�� -�X-o�'T'D�d
ROOFIivG ❑ HOi7SE ONLY BASEMENT REMODELING SUBMIT:
NLJMBER OF SQiJARES ❑ HOL;SE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural membexs to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUC'TiON INCLUDING IlEC.KS,
SIDL�'G ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soffit 1. Site Plan/Survey sho�ving the existing structures
❑ Aluminum � Tnm and proposed project.
❑ Other ❑ Fascia 2, 7'«�o sets of constraction plans
WII�DOWS 3. Energy Calculations
IN EXISTING OPENINGS DYes �No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENING3-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANUES &
TYPE OF WINDOW TO BE INSTALLED NiJMBER OF WINDOWS
ALL �'EES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�,���L�1#�G THE 1997 U.B.0 FEE SCIiEDULE)
TOTAL JOB VALUATION $ � OCCUPANCY 'I'YP'E
Pernut Fee
Plau Review
Fire Surcharge
Surcharge
License Sureharge
SAC Charge
Curb C�t Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
�_. Y�
$
$
$ F
� t1 r
$ �
$
$
$
$
$ `7 I tk"
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Pernut Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2100 per SAC Unit (Plans to MWCC for determination)
�+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineenng
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTN'I'IL PROCESSED
I hereby apply for a building pernut 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 pernut and work is not to start without a permit on site; that the work wifl be in accordance with the
approved plan in the case of all work which requires eview and approval of plans.
SIGNATCJRE OF APPLICANl' PRINT NAME ,Z3r2 /.�;.J GG� �-�`'rF DATE �� 2'� � 8
APPROVAL INSPECTOR SIGNATURE
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