P - 48631Building BUILDING Permit rTo.: �
Inspections RESIDENTIAL APPLICATION Received By
763-572-3604 CITY OF FRIDLEY Da�` '�d� ��
763-502-4977 FAX EFFECTIVE I-1-2012
DATE �� �' 3� i� ` YOUR E-MAIL ADDRESS
SITE ADDRESS �'�f S) '"` � L!� t�✓Y'� �.
THIS APPLICANT IS: OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: �1^<17,�'—J4/ O�- t�--
TENANT ADDRESS: � J�I '"� 3 2l' S��.T ��� Ci'rY �'K- �� �� � STATE ZIP �.� 3Z
PHONE: ��'7..� "` (`o c} `-1 '_ G� C�� c 1..
7
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE INGLE FAtvtILY/tvEw CoNS11tUCT1oN SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE 0 ADDITION ❑ GARAGFJSHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
O DECK SIDING O OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
1NTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: +�'�- c? - /�—G �C . 2s ~!�"-"
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFIN '�% � ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT
NUMBER OF SQUARES �` ❑ HOUSE & GARAGE 1. 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,
❑ Vin 1 � � ❑Soffit SIDING/SOF'FIT/FASCIA ADDITIONS & PORCHES SUBMIT
Y � 1. Site Plan/Survey showing the existing structures
❑ Aluminum (� ❑ Trim REMOVED? ❑ YES ❑ NO and proposed project.
❑ Other �`� ❑ Fascia 2, Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE ST[CKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO B� INSTALLED NUMBER OF WINDOWS
ALL H'I�:L�'.�' AKE liAi.l'N ll UPl VALUAl1VP1� 11Vl..LUL1PIl1 li1L� �,v.�1 vr LLiDVl� t11�L 1�1l11L' 1�LALl)•
USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $�� I E OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ �
$ �
$
$
$
$
$
$
$
�V Y
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 (Sta.te Licensed Residential Contractors)
$2365 per SAC Unit (Plans to MWCC for determination)
ft+68= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building ermit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinan es and codes of the f Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio fo,,�a p it and or is not to staxt without a p rinit on site; tha he work wi 1 be�n accordance with the
approved plan in the case 1` fk ic equ' s r ' w a roval of p j
SIGNATURE OF APPLICANT 'L'l �, �� LL G T NAME itC �^?" r l.� t C/� � TE c3 ` Zs3 ` jd'"