P - 48632Building BUILDING Permit No.:�
Inspections RESIDENTIAL APPLICATION Received By::
763-572-3604 CITY OF FRIDLEY Da;�
763-502-4977 FAX �;tl,"U�� � �. �
EFFECT'IVE 1-1-2012
DATE ��`l'"'� "- � 2 YOURE-MAILADDRESS ���..°��G� �Ul STI�✓G l �� la ��� �
SITE ADDRESS � v 1�[�'DO � f%� �� �� /U Gl
THIS APPLICANT IS: ❑ OWNER I�ONTRACTOR
PROPERTY OWNER/ NAME: � f%RQL �iZ � 4 LSd
TENANT ADDRESS: SP�� �L .%�S �B�'U� CITY STATE ZIP
PHONE:
CONTRACTOR NAME: � f p � c� � STQ Uc T !V �.
SUBMIT A COPY OF STATE LICENSE # (/ 'J�� � C..o LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIF'ICATE OF ADDRESS: l�{0 °l � S .l -�r 'v � CITY gc� „� y STAT'B'�'r"� ZIP 5��35/
INSURANCE PHONE Z- '�i % l FAX �Z� °' 7gZ �� Z�"�
PROPERTY TYPE .�SINGLE FAMILY/NEW CONSTRUCT'ION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITTON ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK �SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDIT'ION
MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ( GO �
SIZE OF IMPROVEMENT . LENGTH d WIDTH HEIGHT S FT Qpd
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 GARQ�GE 3. List of struchual members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
�Jinyl �Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum � Trim REMOVED? ❑ YES ❑ NO 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of constnaction 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 STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
�ING THE 1997 U.B.0 FEE SCHEDULE)
`�' OCCUPANCY
$ �,� . LS
$
$ -�'�' �10
$
$ 4�
$
$
$
$
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 ( )
Make checks oavable to: Citv of Fridley Attacl
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTTL 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 fo a permi work is not to start without a permit on site; that the work will be in accordance with the
appmved plan in the case of all v�iFF#d�T���-review and approval of plan . ��,_,L
SIGNANRE OF APPLICANT PRINT NAME �fC(M v/ �'"!C (,,,G Ll DATE 3-' Z 3" �Z