P - 42372� Z��� ���
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � �."� �
SITE ADDRESS �
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-09
YOUR E-MAIL ADDRESS
4;h �- '��
❑ OWNER �ONTRACTOR
NAME: �
ADDRESS: ,t ��-� r �' ��
PHONE: JI � �"_ �Cr�� "'���_�
CONTRACTOR NAME:LU�j���%
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE #
AND CERTIFICATE OF ADDRESS �
INSURANCE Dunw.� '�(� =
EXP DATE
PROPERTY TYPE `�INGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGElSHED INDOWS
❑ BASEMENT FINISH ❑ ROOF .O DRAIN TILE
❑ DECK ❑ SID1NG ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCElREPAIR ❑ REMODELING
Permit No,
Received By: j �.� �
Dat��i:�UU ,� ��
ATE��LIP S �
DESCRIBE WORK BEING DONE: ��.: � —� � � ` ��� � � C
SIZE OF IMPROVEMENT LENGT DTH HEIGHT SQ FT
ROOFING ❑ 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,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Alumi�um ❑ Trim 1. Site Plan/Survey showing the exisYing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. E�ergy Calculations
IN EXISTING OPENINGS�' es C]No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES & ���;� �L;y1�'
TYPE OF WINDOW TO BE INSTALLED' � �UMBER OF WINDOWS r2{
ALL FEES ARE BASED ON VALUATI N, INCLUDING THE COST OF LABOR AND MATERIALS:
,,,(USIN�G THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
TYPE
$ �� �� ,•?� 5 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �`-�,U .001 times the totai job valuation
$ �_(; V .0005 x Permit Valuation Minimum $.50
$ ��L; �` $5.00 (State Licensed Residential Contractors)
$ $2000 per SAC Unit (Plans to MWCC far determination)
$ ft+6ft= ftx$21=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( }
$ . (L��i .' :'J Make checks navable to: Citv of Fridley Attac
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 far a permit and work is not to start without a permit on site; that the wark will be in accardance with the
approved plan in the case of all work�hich requires view and pproval of plans. �\
SIGNATTJRE OF APPLICANT ��L��S. `�t����'^—' r RINT NAME l.V �� I S�"j 4' u� �) DATE J'�._ 1 V