P - 50484�a-►�?i9 ��b�.�U
�cc�-�- ��c��
Building BUILDING Permit No.:� ,� � �
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX ��e����
EFFECTIVE 1-1-2012
DATE _ I—' I 1✓ �� YOUR/jE-MAIL ADDRESS L� 1Q I l� S� l.�J ( i� �� ��Or I��i D�! � l��
SITE ADDRESS c 1� ���" 1' 11 1�\ e l, i� li�� �� `
THIS APPLICANT IS: ❑ OWNER NTRACTOR
PROPERTY OWNER/ NAME: s
TENANT ,�DRESS: � 1 �� STATE�IUzir�
PHONE: t� ► a - aa � - �55�-I
CONTRACTOR NAME: � I Y7�� l.l_�lJ� �(..1
SUBMIT A COPY OF STATE LICENSE #��� /� p�-�,� LEAD CERT NUMBER ��T'��1'I EXP: �I� �� S
YOUR STATE LICENSE 1 ,�"�, ?/� �y_
AND CERTIFICATE OF ADDRESS: �� i I` I F� /�Y(Tt � '� �c XJ CITYN—D7!(--�► / i c�I �� STATEj�ZIPe�l6�
INSURANCE pHONE I' I { V`" I � FAX �`� I I V'"
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH ❑ ROOF DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES O HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: � DETACHED GARAGE 3. List of shuctural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? O YES 0 NO �• Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two seu of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS'�Oi'es ❑No LOCATION OF WINDOWS FOR Wl`rIDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & 5
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
Pian Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
THE 1997 U.B.0 FEE SCHEDULE)
$
$
$
$ J
$
$
$
$
$ �
OCCUPANCY TYPE
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 navable to: Citv of Fridlev Attach
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 an des of t e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a pe it a 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 all work whic re ' es review and approval of p ans. . �/�y�� `
SIGNATURE OF APPLICANT PRINT NAME e C J ll � J� DATE �— 1� � I�`
APPROVAL INSPECTOR SIGNATU