P - 84225Building BUILDING Permit No.: � �
Inspections RESIDENTIAL APPLICATION xecei�ed By: j�'
763-572-3604 CITY OF FRIDLEY nate
763-502-4977 FAX ��'� M�R 2 4 2�
EFFECTIVE 1-1-2012
DATE � — �� " �� YlOUR E-MAIL ADDRESS
SITE ADDRESS ___ S�o lo D S� /V •L �
THIS APPLICANT IS: �COWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: 4`(� p..�e."� �CJ-� v i�' � `
TENANT ADDRESS: J� g�G� �o� S� /�/ � CITY _/" '1",� d cy- STATE�ZIP J� ^ '3oZ
PHONE: _ 7 C� .� � � r � ' � E� �I
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICAT'E OF ADDRESS: CITY STATE ZIP
INSURANCE HONE FAX
PROPERTY TYPE � 1rrGLE FatvtiLY/t�rEw coNS'rftUC'riotv SIZE
❑ O FAMILY/NEW CONSTRUCTION STORIES
PERMTT TYPE ❑ ADDITIOrr ❑ GARAGE/SHED � WINDOWS
❑ BASEMENT FIMSH �ItOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: Uo-� C'� O S�-'�-
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
R FING ��,� � HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES � O HOUSE & GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GAR¢1GE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSIRUCT'!ON INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMTf:
❑ Atuminum O Trim REMOVED? ❑ YES ❑ NO �• Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOW3 3. Energy Calculations
IN EXISTING OPEb1INGS ❑Yes ONo 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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee �
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
TYPE
$ '�!) °�,�7 See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ _.001 times the total job valuation
$ .0005 x Permit Valuation Minimum or .50
$ $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 ( )
$ � Make checks payable to: Citv of Fridley 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 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 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 I work which r ui review and approval of p ans. �►/�
SIGNATURE OF APPLICANT � �f PRINT NAME �Q{YI e i 1 t �� v ti Y � DATE 3- 0�0 ^( 07-
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