P - 42125Building BUILDING Permit No.: � � �
Inspections RESIDENTIAL APPLICATION Recei�. '
763-572-3604 CITY OF FRIDLEY Date Rec'd:
763-502-4977 FAX EFFECTNE 1-1-09
DATE ��'y !l YOURE-MAILADDRESS ICLt%I$OYlL�Y!%?U�f"'.�"AiYI
siTE EwD�ss �/3 %�e �, n g f� i�,^; ve I��� i�'i"% o�lr.-.� 6�7it5�43 �
THIS APPLICANT IS: ❑ OWNER L�CONTRACTOR
PROPERTY OWNER/ NA1vt�: � o- Pp ��^Z W�
TENANT ADDRESS: %I G i(/G %?G CITY t STAT�ZIP�j�
PHONE:
CONTRACTOR NAME: ��I� �If �-�Y6 2�y�-�,�� 1 n� /
SUBMIT A COPY OF STATE LICENSE # -*% % EXP DATE �' 3!' I�
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS:��vG4'7 I e '�fSo'�'1 l�w� crrYDSS'�d STATF%��ZIP�
INSURANCE pHONE 7G ' �'I /• �� FAX �G� 3' D
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �d-Rt7bF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCElREPAIl2 ❑ REMODELING
DESCRIBE WORK BEING DONE�i�� G %�?" �t�I�.t !�!'dly7 �7D1�5c. � gty-f?2c/ C. L'�I't5�aCif��rcJSG<<rjclG�"J1�'104�c��
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT � S FT
ROOFING � ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �'2?bUSE & GARAGE 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 ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. 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 ❑No LOCATION OF WINDOWS
OR FOR NEW OPEIdINGS-DESCRIBE SIZE OF
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)
'OTAL JOB VALUATION $/_`� 9�'d• �D OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �-� � a� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
�(� .001 times the total job valuation
$ � _ .0005 x Permit Valuation Minimum $.50
$ �Q $5.00 (State Licensed Residential Contractors)
$ $2000 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$21=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ n7_ Cr7 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
conform ce with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit b t nly an pplication for a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved pl in case of a ork w c e ir �eview and approval of pl s.
SIGNATURE C�F� If ���I�� r PRINT NAME�iT�%/��` Sd � DATE IO "'I ' l(
SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK
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