P - 48348Buildillg $jJjj,�jN(i Permit No.. L� �,�,," ��� �'
Inspections RESIDENTIAL APPLICATION Received By����
763-572-3604 CITY OF FRIDLEY �'� �� �
763-502-4977 FAX EFFECTNE 1-1-2011
DATE � I YO�U,{R E-MAIL ADDRESS ` S ��' G �.�� 4� � Z[ C� %%. P(�/�
SITE ADDRESS � . � ��)��%� I1� /„�'P IU ��
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THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY OWNER/ NAME: � , G; �' � ,
TENANT a��aESS: � �G� � .�"1� �� � �� ctTY � sTaTE ziP��
� ,. � , n „
PHONE: �7
CONTRACTOR NAME: � � S �
SUBMIT A COPY OF STATE LICENSE # � -/� LEAD CERT NUMBER
YOUR STATE LICENSE �
AND CERTIFICATE OF ADDRESS: ��� I� � a�� S� �.� CITY �� � G� STATE�LIP ��' �
INSURANCE PHONE Z� � Z�% �� FAX � `,/ �� 7 '�
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCT[ON SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION � j 4i� r� ,
❑ MAINTENANCE/REPAIR ❑ REMODELING t li`-�
DESCRIBE WORK BEING DONE: �� f �� (�/ � GL�1�
SIZE OF IMPROVEMENT LENGTH � WIDT HEIGHT SQ FT
ROOFING y, � ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �✓'� 1�IOUSE & GARAGE
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 ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ 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 NEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION $ �� ��jS� �T}� 1997 U.B.0 FEE SCH 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
$ � 7J'�. L� �� �.L� See Back Page for Fee Schedule
$ 65°/a of Building Permit Fee
$ � .001 times the total job valuation
$ . � � �� .0005 x Permit Valuation Minimum $5.00
$ -rj- (; (�_�; �� („°,' $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ , , __ _ 4lgreement necessary ( ) Non Necessary ( )
ake checks payable to: City of Fridley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 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 a r which u e,r iew and approval of plans y y )�
SIGNATURE OF APPLICANT �j ���j� PRINT NAME �(,�� ��7 � DATE �y �� � I I
APPROVAL INSPECTOR SIGNATl.�RE '� —
PLEASE NOTE: SEPARAT`E PERMITS ARE REOUIRED FOR PLUMBING, ELECTRICAL AND MECHA1vICAL WORK