P - 48620Building BUILDING Perrnit rro.: � (� �3
Inspections RESIDENTIAL APPLICATION Recei�;�: �
763-s�2-3604 CITY OF FRIDLEY Date Rec'd:
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE � � ' �� YOUR E-MAIL ADDRESS /�I � CC� (�'� 4fGs �d (4- C�riYl/�
SITEADDRESS �Q 3J � � . �'��E �
THIS APPLICANT IS: ❑ OWNER �60NTRACTOR
PROPERTY OWNER/ NAME: S J
TENANT pDDRESS: �e,�S I ��° S'- J�II� CI71' � y� �/ STATE ZIP�
PHONE: %(p .�� 'rj� I "' j � % F�
CONTRACTOR NAME: `l' �S s� c S ��� �
SUBMIT A COPY OF STATE LICENSE #� 3 J�' �- C� LEAD CERT NUMBER EXP:
YOUR STATE LICENSE �
AND CERTIFICATE OF ADDRESS: ,`L� G-�o�i'�.t�-�-p� Qr�. CITYN�tc��^+� i tQ Il� STATE�ZIP�S
INSURANCE PHONE 0��^ " 7O �$ FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGFJSHED � WINDOWS
❑ BASEMENT FIIdISH �.ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:' `� e. y r'�"
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING � ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GAR,AGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑3offit SIDING/SOFFIT/FASCIA ADDITiONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? � YES O NO �• Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXIST[NG OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACNRE STICKER ON WINDOW.
OPEI�iING 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 $
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
(USING THE 1997 U.B.0 FEE SCHEDULE)
OCCUPANCY
$ �"� ��_ ��_ 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 ( )
$ �(7`I :�L Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERNIIT-NOT VALID UNTTL 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�ll work wjl�ch requires review and approval of pl� s) 3—a �� �a
SIGNATURE OF APPLICANT %`�'�'`7 � PRINT NAME /"�lC�, W� �,-}�l�%S'ell� DATE