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Building BUILDING Pe�it vo.: '
Inspections RESIDENTIAL APPLICATION Re�ei�ea By:
763-572-3604 CITY OF FRIDLEY Da�' �
763-5�2,4977 FAx EFFECTNE 7-1-2010
DATE (�.�" ��`" � V �� �a YOUR E-MAIL ADDRESS
S�TE �D�SS ld �`•,�� i� -� Gc..�p-c N�=
THIS APPLICANT IS: ❑ OWNER 'L�ONTRACTOR
PROPERTY OWNER/ NAME: ' � �•y�
TENANT .�D[�ss: ;� �' ci� YLt. sTATEI'hnrzir � "
� PH�NE: -7 � � �C� �- �l aG.
CONTRACTOR NAME: (J ` �1 ' C�vJ�-f -�,.�
SUBMIT A COPY OF STATE LICENSE #„� C�' ��� �/ V EXP DATE ` �� "
YOUR STATE LICENSE � y-��
AND CERTIFICATE OF ADDRESS:�, C�� �W %�h' �jI`. SL�� �'� J�_CITY /ZJ�� cCj� � STAT�%'1t`/ZIP�_ CS-
INSURANCE pHONE ' a FAX ,�'!� 'O%
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERIVIIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH "�ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
� ❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � -' �
SIZE OF IMPROVEMENT LENGTH IDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES �� �HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
I . 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 OSoffit ADDITIONS. & PORCHES SUBMIT:
O Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL N'��� Ald� l3ASL+'ll U1V VALU�'1'lU1V, i1�li:LlJll1NEr'1'Hl: (;U�"1' UN' LABURr11Vll MA'TERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ C�, � Dr� _ r'�C> 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
$ f� s�j See Back Page for Fee Schedule
$ __ 65% of Building Permit Fee
$ _.001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ rj"vl, $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 ( )
$ h M_ Make checks pavable to: Citv of Fridlev Attach
THIS IS AN AP°LICAT:ON FOR A PEii1�fIT-t�^vT Vr`,L,ID iJi�'TIL PROCESSED
I hereby apply for a building permit and I cknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of e City of Fridley and with the Minnesota Constnzction Codes; that I understand this is not a
permit but only an application for a permit and is not to start without a permit on site; that the wark will be in accordance with the
approved plan in the case o l�,wo w ich req ir s 'ew ar.d approval of plans. (� �"�
SIGNATURE OF APPLICANT PRINT NAME � j/� � rJ !' / Q ry� DATE �-!3 ao 1�
APPROVAL TNSPECTOR SIGNATU -�
>; PLEASE NOTE: SEPARATE PERMITS �E p�(??UIRED.FOR PLUMBING