P - 42751Building BUILDING Permit No.:� � I "�
Inspections RESIDENTIAL APPLICATION Received By: !�
763-572-3604 CITY OF FRIDLEY D���a��!�'; f���D��
763-502-4977 FAX �.
EFEECTIVE 1-1-2010
DATE f'� �"� YOUR E-MAIL ADDRESS
SITEADDRESS %�� �i �° //I��
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: t'T' d- �� r/o
TENANT ADDRESS:_l l� �l �-�f /"���- '�� CITY j�i/ � ja'l4 STAT�n, ZIP
PHONE: �
CONTRACTOR NpME: �•-rc,s J r� iv� G�
SUBMIT A COPY OF STATE LICENSE # lJ.� 7� EXP DATE Zid I%
YOUR STATE LICENSE p �ry!
AND CERTIFICATE OF ADDRESS: /' i 1�1r 4 j„ � CITY �--u� C�- STAir/ ���ZIP�
INSURANCE PHONE Z' L Z� "`I �? � FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: 2 ,-c, � hs ��oc�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING p HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
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:
❑ 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 17No 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 N'r;r;S AKL BA�r;ll VN VALUA'1'lUN, 1NCLUll1NG "1'HE COST Ul�' LABUR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $; 5_�a 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
$ /� �rJ,�s See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ G .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 ( )
$ I (�: Make checks oavable to: Citv of Fridlev 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 for a permit d 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 all wor w' equires review a approvai of plans.
SIGNATURE OF APPLIC PRINT NAME%'�+- �,��L� DATE ��' / //