P - 48230Building BUILDING Pe��t No.:'��� ���` �`�
Inspections RESIDENTIAL APPLICATION Rec
763-572-3604 �� .' .� � ;� .
763-502-4977 FAX CITY OF FRIDLEY vate xec'ct:
EFFECTIVE 11-2011
DATE I � �� O �I YOUR E-MAIL ADDRESS �/�O �c `"Z��G.�cS� ��G'� � �O M
SITE ADDRESS I 3 S� %S Ig�i �1�
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: e� �00 K
TENANT ADDRESS: 7 �N� c��ry �
� � �f' STATE%�7/�'LIP�_
PHONE: �%i � ' � yG SI
CONTRACTOR NAME: � �Sf f, �S' � �-,�o�
SUBMIT A COPY OF STATE LICENSE #_ �O e�Z 7 7 LEAD CERT NUMBER 3 �I EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS:__��5,� rW/G �� Z/- CITY �� I.L STATE /''�ZIP
INSURANCE PHONE .�� 8D'�.3��'
FAX
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK �SIDING O OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: i-T./t,S`/'�' �' O� �%� CG�/'Q�'►S/ j��'or"�{j �' -��i �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
R ING ❑ HOUSE ONLY $ASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE �, Existing Floor P1an
GAItAGES ❑ AT"fACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION [NCLUDING DECKS,
Vinyl '�Soffit SIDING/SOFFIT,(F�ASCIA ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? I�YES ❑ NO �• Site Plan/Survey showing the existing structures
❑ Other (����a and proposed project.
2. Two sets of construction plans
WINDOWS 3. Enetgy Calculations
IN EXISTING OPENINGS R�j'es ONo LOCATION OF WINDOWS �2.�1,'fC.�o^ /� v� FOR WINDOWS - PROVTDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STTCKER ON WINDOW.
OPENING CHANGES & S�I �pt>>"
TYPE OF WINDOW TO BE INSTALLED � NUMBER OF WINDOWS 3
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
'OTAL JOB VALUATION
Permit Fee
Plan Review
Fire Suroharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
(USING THE 1997 U.B.0 FEE SCHEDULE)
L) B �' OCCUP,
$ LUy. �--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)
$ �+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
-$ �}-. Agreement necessary ( ) Non Necessary ( )
� L�K Make checks payable to: City_ 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 wiil 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 applicatio fo • a ei ' d work is n�ot �start without a permit on site; that the work will be in accordance with the
approved plan in the case of i�and approval of plans J���� /��/
SIGNANRE OF APPLICANT �^^ PRINT NAME �/���/ /'��'4��" cY� DATE l il �O��Q /�