P - 48024Building BUILDING Permit No..� �} `�,,C�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vat e d �'
763-502-4977 FAX EFFECTIVE 11-2011 ��� � �
DATE �" ` ' � � YOUR E-MAIL ADDRESS
SITE ADDRESS � f /�,� �I�'L% /�� � � f — / �o �
THIS APPLICANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME:
TENANT ADDRESS: CITY STATE ZIP
PHONE:
CONTRACTOR NAME: i� . S L� � �
SUBMIT A COPY OF � ��
YOUR STATE LICENSE STATE LICENSE # L D CERT NUMBE "' ��
AND CERTIFICATE OF ADDRESS: �J � CITY �L 5�� STAT�O�ZIP,��p�[�
INSURANCE PHONE / �� 76 FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
� TWO FAMILYMEW 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
❑ M T NC PAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: `�`
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES�� ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
l. Existing Floor Plan �
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: O DETACHED GARAGE 3. List of structural members to be used I
PROPOSED HEIGHT: I
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vin 1 ADDITIONS. & PORCHES SUBMIT
Y ❑Soffit SIDING/SOFFIT/FASCIA I. Site Plan/Surve showin the existin structures
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO and proposed p oject. g g
❑ Other ❑ Fascia
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTTNG 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 FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
$ `1 ~l .%� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ � 3 J .001 times the total job valuation
$ '' .0005 x Permit Valuation Minimum $5.00
$ $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
$ Agreement necessary ( ) Non Necessary ( )
$ I b� . _ Make checks payable to: City of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LJNTIL PROCESSED
I hereby apply for a building e't and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ord�es a codes of tfiie Cit f Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an app�ation a p it and wor ' not to sta without a ermit o site; that the work will be in accordance with the
approved plan in the case of w r '.c equ' reviej�a.�d roval of pl /
SIGNANRE OF APPLICANT RINT NAME � %Gt o i��' � DATE �� �� '�/
APPROVALINSPECTORS . J . .