P - 48626Building BUILDING Perrnit Ivo.:
Inspections RESIDENTIAL APPLICATION Received By:l�i�%'
763-572-3604 CITY OF FRIDLEY Date �"c� MI�R `� 2 0
763-502-4977 FAX EFFECTIVE 1-i-2012
DATE � 01- � t v� YOUR E-MAIL ADDRESS � GCL � f.�_ � I`l� F`VlA /�t �GU 1'1� C<c S�. ���
SITE ADDRESS �Z CP �'�' N
THIS APPLICANT IS: �OWNER �CONTRACTOR
PROPERTY OWNER/ 'NAME: • " r- C� �-[,L i I`t�LQ K,
TENANT pDDRESS: "`F'Gt, S ITY �V i� �'P �STATE� IP �J�"E 32
PHONE: "-T j 17 3���`��� a-a 'rj'
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCT'ION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED 0 WINDOWS
❑ BASEMENT FRIISH �tOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCEJREPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �` __ I� ,S f�G 'G�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING j ❑ HOUSE ONLY
NUMBER OF SQUARES `�� ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARQ,GE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
O Vinyl ❑Soffit SIDINGlSO�'FIT/FASCIA ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES 0 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 OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE ST'ICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL N'r;�;5 AK� BASEll ON VALUATlON,1NCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
JOB VALUATION $ 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
$ (����j 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 ( )
$ - Q Make checks aavable to: Citv of Fridlev 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 o c whic r quin evi�w and approval of plan r, � . f
SFGNATURE OF APPLICANT /]�� �,-� PRINT NAME �D� C F'-f �� f�� ���E ��I��l �
APPROVAL INSPECTOR SIGNATURE °I�-