P - 42368Building BUILDING PermitNo.:���,(�1� Ij'��I
Inspections RESIDENTIAL APPLICATION Received By: ��
763-572-3604 CITY OF FRIDLEY Date ��
763-502-4977 FAX EFFECTIVE 7-1-2010 ��� ' - �
DATE Q 7"' � y��� YOURE-MAIL ADDRESS �' ���`����`�`"`�h°`�'`�5-Cc���t
SITE ADDRESS � ��� Si"� ���•
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
❑ OWNER �ONTRACTOR
NAME: �Q+� S..fu.�f�ti
ADDRESS: �`4'0`� S�" j`�� CITY (_.��� fe
ov��7�. 7 — 5 -`�c� �
NAME: 'li'� Cx f'�.aur.�� �'Z„
'ATE 6'""� ZIP
STATE LICENSE #�v� ��- � j$ EXP DATE � ��i !��° `�
ADDRESS: J 3� W ���` �' CITY � r S STATE ZIP
PROPERTY TYPE � SINGLE FAMILY/I�IEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES Z
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ADDITION ❑ GARAG
❑ BASEMENT FINISH �. ROOF
� DECK ❑ SIDING
❑ NEW HOME CONSTRUCTION
❑ MAINTENANCE/REPAIR
f�e - 12Uc
NG POOL
❑ ADDITION
� REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
Q DETACHED GARAGE
❑Soffit
O Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NBW OPENINGS-DESCR[BE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLBD NUMBER OF \
❑ WINDOWS
❑ DRAIN TILE
❑ OTHER
FT � f
BASEMENT REMODELING Si1BMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project,
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUB AND
MANUFACTURE STICKER ON WINDOW.
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Pire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
i Total Due
� �'3 3 �
$ �
$
$
$ �7
$
$
$
$
$
See Back Page for Fee Schedule
65°/a of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractars)
$2100 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Bngineering
Agreement necessary ( ) Non Necessary ( )
Ma[ce checks payabte to: Citv of Fridlev Attach
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 accwate; 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 pertnit 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 al k which uires review and approval of plans. ��,r
SIGNATURE OF APPLICANT � PRINT NAME 'r''"� �r`'`' z DATE D 7�[ S" �C�
APPROVAL INSPECTOR SIGNATURE