P - 43145Bui�ldi�g BUILDING Permit 1vo.:a ° ���`a
Ins�ctions RESIDENTIAL APPLICATION Received By: {�
763- 72-3604 CITY OF FRIDLEY vat
763-502-4977 FAX ���''� '�
EFFECTTVE 1-]-2010
DATE � Gl ���`� �—�r YOUR E-MAIL ADDRESS
SIT'E ADDRESS / :;�i / �` �c- �� ` ,�'�.,.��. �'ii� (�'
THIS APPLICANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME:�>i.z ,�,g�,�f'/��
TENANT ADDRESS:�.f 7�% Zfr_�'� /j/�(� CITY �/l l.�/�y STATEg�ZIP ;�SY3?
PHONE:_( /Z -- �'O %— �� 3�
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # EXP DATE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH O ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION J�'ADDI1'ION
❑ MAINTENANCE/REPAIR 0 REMODELING
DESCRIBE WORK BEING DONE: bt k� �!J Ga� rq qe -
SIZE OF IMPROVEMENT LENGTH Z WIDTH Z� HEIGHT� I� S S FT 0
R O G ❑ HOUSE ONLY BASEMENT REMODE1.tNG SUBMIT•
NUMBER OF SQUARES ❑ HOUSE & GARAGE �, Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2.. Proposed floor plan
PROPOSED SIZE: �° X�L �A.DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT: �.uq//s y�
ID G �,3% '� �%��/dk C4 L�(� t'� FOR NEW CONSTRUCTION INCLUDING DECKS,
Vin t ADDITIONS. & PORCHEc ci�gM1T
Y ❑Soffit ��� �4 �. Site Plan/Survey showing the existing structures
Aluminum ❑ Trim and proposed project.
❑ Other �a��a 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCAT[ON OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE S'ITCKER 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 $ q,(aQ 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
3 D' `�1 �` `�_ See Back Page for Fee Schedule
$ i 65% of Building Permit Fee
$ l . .001 times the total job valuation
$ .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 ( )
$ Make checks payable to: City of Fridle.y Attach
THIS IS AN APPLICATTON 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 all work which requires review and approval of plans.
SIGNATURE OF APPLICANT �U�'�� �>��'"''� PRINT NAME�G /h1 �/%�� £/l'� DATE_ _] — / �" �l�
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