P - 35475Building BUILDING Permit No.: �' � G� ��US�
Inspections RESIDENTIAL APPLICATION Received By:.i41
763-572-3604
763-502-4977 FAX CITY OF FRIDLEY Date Rec'ct: �--' �'���
EFFEC7TVE 1-1-2010
DATE f� � 7 �� YOUR E-MAIL ADDRESS
SITE ADD� ._L2_! 9 ��✓r/% l�/}"�„ .� �/L� ��' , C� � Y%L �-' % %�lll/�
THIS APPLICANT IS: �`OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: ,�"I�Q/�/U ti"� �L�'%CS �� U� ��G �
TENANT ADDRESS: CITY STATE ZIP
PHONE:
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE �! EXP DATE
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STA7'E ZIP
INSURANCE PHONE FAX
PROPERTY TYPE ,�-SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION O GARAGE/SHED WINDOWS
❑ BASEMENT FINISH Q ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDI7TON
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING la HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
l. Existin$ Floor Plan
GARAGES � ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
�IDING FOR NEW CONSTRUCTION 1NCLUDING DECKS,
❑ Vinyl OSoffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum C] Trim 1• Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. . Two sets of conswction plans
yVINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCA QI�i OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF '' �c�'J /i� t vz ���C� MANUFACTURE S"1'ICKER 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:
�iJS1,NGSHE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $� G.S f��U OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Tota! Due
$
$ t �i5
$ .
$
$
$
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)
$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 ( )
Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby appiy for a buiiding permit and I aclrnowledge 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 ' w and approval of plans.
SIGNATURE OF APPLICAN�� PRINT NAME ���f�/ i""��/U�ATE �/ �/v
� �