P - 35321Building BUILDING Permit No.: �C� Q�
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY Dat����� ������
763-502-4977 FAX EFFECTIVE 1-1-09
DATE / � YOUR E-MAIL ADDRESS G�YO� i��� v����5 ` i�CT
SITE ADDRESS �loDO �>'�AGt ��I J/• /U/ �.
THIS APPLICANT [5: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NpME: y.�•Z ,� � �
TENANT p,�DRESS:%l�DD ,B✓MRr��� /tI� CITY /"'yi ef �'+G� STATE /� ZIP
PHONE:,�G_�"%I�i2"� �ISO
CONTRACTOR NAME: S✓rLu�t,rL� t G�wtl �Y'�G i o-c�
SUBMIT A COPY OF STATE LICENSE # EXP DATE 3 3 ��
YOUR STATE LICENSE
AND CERTIFICATE OF �wD�ss:,�33,y � v.� `-'✓it�e� S. CITY � � STAT6r��IP �.s
INSURANCE pHONE � ^ ,.7�—�023 FAX -- � ^ �--�--3
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/�IEW CONSTRUCTION STORIES
PERMIT TYPE ❑ �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRA(N TILE
O DECK ❑ S[DiNG ❑ OTHER
— ❑ SWIMMING POOL '
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDIT[ON
MA[NTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: 4�-
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING O HOUSE ONLY
NUMBER OF SQUARES -3e ❑ HOUSE & GARAGE BASEMENT REMODELMG 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: C�`
SIDING � FOR NEW CONSTRUCTION INCLUD[NG DECKS,
0 Vinyl , ❑Soffit ADDITION3. & PORCHES SUBMIT:
O Aluminum ❑ Trim �\ 1. Site PlanlSurvey showing the existing structures
❑ Other 0 Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
M EXISTING OPENINGS ❑Yes I�No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE S[ZE OF
OPENING CHANGES &
TYPE OF,WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST UF LABUR AND MATERIALS:
TOTAL JOB VALUATION $ !�� �HE�a9r�9�7biJ.B.0 FEE SCHOCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ �' 1
$ a �1
$ S
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$2000 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$22=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks aavable to: Citv of Fridlev Attach
THI$ [S 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 work wh'ch re ire �yie v and approval of plans.
SIGNATUI2E OF APPLIC � �!.� ��'-s'��RINT NAM ✓Y i� !� DATE � �