P - 36785Building BUILDING Pe�itNo.�:� �� =� �
Inspections RESIDENTIAL APPLICATION Received B�
763-572-3604 '
CITY OF FRIDLEY Date ��� - � �
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE � �� ` ! / YOUR E-MAIL ADDRESS
SITE ADDRESS '7 7� 7 � Sf ��
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: !�/hJ /'�-,°
TENANT aDD�ss: � /�.C�rY it �� sTAT tP�
PHONE: S�71— �-
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER ��
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: /7�."�1 R'77 9�77 CITY STATE ZIP
INSURANCE pgp 'FAX
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ RO F ❑ DRAIN TILE
❑ DECK DING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �`�/B�'l� I� �N 5�"� L
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES O 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:
S FOR NEW CONSTRUCTION INCLUDING DECKS,
Vinyl ❑Soff"it ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS 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
ALL FEES ALZ� BAS�D UN vALUA11Uiv, 11V(:LUlll1VCi 1Hr; C:U�1 Vr LAKVl( A1VL 1V1A1L+KIALJ:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ S_oZBfj . cTU 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
$ �p�s �d,,5 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors}
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
—$ —�.�q--�— Agreement necessary ( ) Non Necessary ( )
� I,°IIAi .(b Make checks pavable to: City of Fridiey Attach
THIS 15 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 d codes the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application p and w k is not to start without a p mit on sit , that the wo will be in accordance with the
approved plan in the case of al r eview and approval of pla . d �i / ��A� �—� I
SIGNATURE OF APPLICANT PRINT NAME /'� U� ��� �