P - 48417Building BUILDING Pern�it Ivo.� i�1 '� I
Inspections RESIDENTIAL APPLICATION Received By: _
763-572-3604
�63-so2-49�� FAx CITY OF FRIDLEY ���°�:�- P.� ��� ���
EFFECTIVE 1-1-2012
DATE v� 3 � 2 YOUR E-MAIL ADDRESS Jo �✓1 � c� c�%L' �1Pr' /✓IC . CO �T
SITE ADDRESS 9D GG � WGV N�
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: �F c u/q G
TENANT ADDRESS: � G� a CITY �i�ct �eti STATE�IVZIP ,ts�3o2
PHONE: 7G J- S7J' �o�� G
CONTRACTOR NAME: �,�J,.pI�� : �/ �L�1-
SUBMIT A COPY OF STATE LICENSE # �o� 3 7a 7 LEAD CERT NUMBER �T /04 S47 EXP: /y�fa.tl� �/ , gOl L
YOUR STATE LICENSE �T 1L
AND CERTIFICATE OF ADDRESS: /fj Gli'�u'' G�cti,.. JI/�- CITY F�o(loT_STATE �II✓ZIP ,5�4.�
INSURANCE PHONE `7 �' FAX % ' � - .3� .3 %
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE f,s` 6��
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF O DRAIN TILE
❑ DECK � SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION � ADDITION
❑ MAINTENANCE/REPAIR �I REMODELING
DESCRIBE WORK BEING DONE: � T t..- Q� ry�„fo✓� `-� a�� �(-- �('P..Qltct M/�`f T� �/%/1!'� a/sa 5��+�} -�a9t� q
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE �. Existing Floor Plan
GARAGES ,£9 AT7ACHED 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,
6�Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO � 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 ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $ 5-�Q� G� HE 1997 U.B.0 FEE SCHOCCU ANCY 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
$ �' �'t:s .001 times the total job valuation
$ " .0005 x Permit Valuation Minimum or .50
$ �",� �1 $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ t`� .��`j Make checks payable to: City of Fridley Attach Stiaulations
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 f a�rmit 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 o• which s review and approval of plans` // /
SIGNATURE OF APPLICANT PRINTNAME Jo� it � G(�fGbfi� DATE a�3 �oJ
APPROVAL INSPECTOR SIG RE