P - 84332Building BUILDING Permit Na� I�'U ��
Inspections RESIDENTIAL APPLICATION Received By��'�'�
763-572-3604 CITY OF FRIDLEY Date `' �` ��`
763-502-4977 FAX � �
EFFECTIVE 1-1-2012
DATE I~� ���'`l — 1 O�- YOU E-MAIL ADDRESS
SITE ADDRESS _� 3 � � � `� � � �
THIS APPLICANT IS: ❑ OWNER p�f1Q"PRACTOR
PROPERTY OWNER/ NAME: �{ U 1^ i Y L
TENANT ADDRESS: � 3 �3 �- �j L� � TY
� STAT�\�'�ZIP
PHONE: �I��j ''f " � � �
CONTRACTOR NAME: — � -i- h�. �dsv�S �
SUBMIT A COPY OF STATE LICENSE # ����3 a^I S� LEAD CERT NUMBER I V C� 3��— � EXP: � 31 `( 3
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: Ct� I-1 � ��� ��� CITY STATE�IP�
INSURANCE PHONE %�j � ` �'I ��—' �l� FAX � Cc — � "� G I �'
PROPERTY TYPE �3ffSGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH B1FSbF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�'1GL�iINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: 1�� YG'C�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED 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,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS & PORCHES SUBMIT:
❑ Aluminum � Trim REMOVED? ❑ YES ❑ NO �• Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENIN�rS �Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACNRE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL N'Lr;S ARr: 13ASr;ll UN VALUA"1'IUN, 1NCLUll1NG'1'HE CUS'1' ON LABUR ANll MA"1'EKIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ .Z" See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ '�y�E( .001 times the total job valuation
Surcharge $ � .0005 x Permit Valuation Minimum or .50
License Surcharge $ �"'-„ 6 $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2365 per SAC Unit (Plans to NIWCC for determination)
Curb Cut Escrow $ ft+ 6 ft = ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ ��. (J�- — 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 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 r which-re ' es review and approval of DATE �����" ��.
SIGNATURE OF APPLICANT � PRINT NAME� C3 �
APPROVAL INSPECTOR SIGNATURE