P - 35117Building BUILDING Pe�it r�o.: � �
Inspections RESIDENTIAL APPLICATION Receivect By: .
�63-s�2-3604 CITY OF FRIDLEY Dat : 1 i'ti �I �� C� �
763-502-4977 FAX EFFECTIVE 1-i-2010 ��
DATE �� ���' �I i_ /YOUR E-MAIL ADDRESS I?7►'8 I'l���y tA1� •�
SITE ADDRESS oZ � �� Yri Il.�%�% Z
THIS APPLICANT IS� ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME:
TENANT ADDRESS: " S� CITY STATE IP Ss'" 3a
PHONE:_ 7�7 H �.� %O� ''/PGI
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # a o� 3 6S �� EXP DATE 3�3 i'' �� Z
YOUR STATE LICENSE
AND CERT'IFICATE OF ADDRESS: i CITY / STAT A/ ZIP 5'Soqa
INSURANCE PHONE � � FAX 7 'Q
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE �
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE O ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRATN TILE
0 DECK O SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCT'ION ❑ ADDITION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: f
SIZE OF 1MPROVEMENT LENGTH WIDTH HEIGHT S FT
ItOOFING � qi ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �� 1� HOUSE & GARAGE I, 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 CONSTRUCTTON INCLUDING DECKS,
O Vinyl ❑Soffit ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing stnacturos
and proposed project.
❑ Other ❑ Fascia 2, Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTfNG OPENINGS ❑Yes �No LOCATION OF WLNDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
Ai,i, rr.r;� axL is.�,i;i� VPl vALUA l lutv, IiVCLUll11VG'1'HL CVS"1' Ur LABUK AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION S 9Dl0,� �`. nrCiiPANCY TVPF.
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � �( ���5 See Back Page for Fee Schedule
$ _ 65% of Building Permit Fee
$ _.001 times the total job valuation
$ a .0005 x Permit Valuation Minimum $.50
$ $5.00 (State Licensed Residential Contractors)
$ � $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering .
$ Agreement necessary ( ) Non Necessary ( )
S . � ,� Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VAL1D UNTTL 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 I work w' requ' s re ew and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME__ _/ �d7 /�� lG/���` DATE l��l �I