P - 48553Building BUILDING Permit No.: �► �
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vateRe�'d:3-2.��1
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE �� 2' � Z YOUR E-MAIL ADDRESS
SITE ADDRESS 6 2� C�� r�s � S-�-
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: �S �+-� << �i � I e� c ttic �-
TENANT ADDRESS: CITY STATE ZIP
PHONE:
CONTRACTOR NAME: _ S"1� � (o e� ��.. r,. e rioc ,� a,., �� e,,•� d e� � 1�` ..i y
SUBMIT A COPY OF STATE LICENSE # 8G C 2 7 Z G I EXP: ( S
YOUR STATE LICENSE LEAD CERT NUMBER �� sy G" �
AND CERTIFICATE OF ADDRESS: ��� 3 .4 i ya ;.� e o� /' CITI' �'�. �"'� S e v STATE s4. ZIP SS 3 0 3
INSURANCE PHONE � G 3` S 7 6 - I 1� 3 pp}{
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTTON STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDpW3
�BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK � SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: d�2 ..ti ov-� 1.�.a.. )� S 1+-t-�.v it ��G �S c« �. � j� 5 %,P d y- y-a .� ���„ b�, s'e .•�-c �. -�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
R� ING ❑ HOUSE ONLY BASEMENT REMODELIN SUBMIT•
NiJMBER OF SQUARES � HOUSE & 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 SIDING/SOFFIT/FASCIA ADDITIONS_ & PORCHES S MIT:
❑ Aluminum ❑ Trim REMOVED? � YES ❑ NO �� 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 ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENRIGS-DESCffiBE 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 CO5T OF LABOR AND MATERiAi,S_
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
! Park Fee
! Sewer Main Charge
' Total Due
(USING THE 1997 U.B.0 FEE SCHEDULE)
S. �� __ OCCUPANCY
$ l 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 payabte to: City of Fridlev Attact
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
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 onty 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 allyuer�uvhic �quires review and approval of plans.
SIGNATURE OF APPLICANI'_� i"'� � PRINT NAME � L+�-n.e l: � S�r c°} DATE 3' >^ 1�
APPROVAL INSPECTOR SIGNAT[IRR
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