P - 42333Buiiding � BUILDING permit r1o.: !�'� `� � ��
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY D �
763-502-4977 FAX EFFECTIVE 1-1-2010 ��� ����—�-�Q
DATE F� " l�'" /� YOUR E-MAIL ADDRESS C✓' p:.✓a.�/ � I
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THIS APPLICANT IS: �vWNER OCONTRACTOR
PROPERTY OWNER/ NAME: .� G,-,.�� C 1%� v� l r
TENANT ADDRESS: J oZ �j U �02-..�c� ��^"�� CITY y i" � c� l r� STATF� �✓ZIP�y�2
PHONE: % �j � ", ,j % ! " � �O �
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # EXP DATE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH [7 ROOF ❑ DRAIN TILE
Q DECK �SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�'h4AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: s i G� i v�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
l. Existing Floor Plan
GARAGES ❑ A7"1'ACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: � DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
IDING FOR NEW CONSTRUCTION INCLUDING DECKS,
Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT
❑ Alutninum Q Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS DYes ONo GOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACNRE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL 1+1�:�J AKE 1fA1L� ll V1V VALUAl1VN� LNCLUll1NCG "i'HE CU5"I' UP' LABUR AND MATERIALS:
�/ (USING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION $ 4 O �% OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ � .0005 x Permit Valuation Minimnm $.50
$ 5�� $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 (
Make checks �avable to: Ciri of Fridlev
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a buitding permit and I acknowledge that the information above is complete ar�d accurate; tl�at 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 perrr►it on site; that the work will be in accordance with the
approved plan in the case ork which equires review and approval of plans.
SIGNANRE OF APPLICAN'� (/ � PRINT NAME �Q h.t S V R N-� DATE �"jD ���