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Building BUILDING Permit r�o.: . U�
Inspections RESIDENTIAL APPLICATION R ceived B:
763-572-3604 CITY OF FRIDLEY D������Q � 0
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE YOUR E-MAIL ADDRESS /!�/ �(�, �C �LM�t 14v1_ � W 1�heP� W CONC� fv1 Il. C O l�1
s1� aDD�ss SS85 � �f�,./,'�, n��^�lQ
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME:�p � T'ac K SO t1
TENANT ADDRESS:_ SS$"S E �i7Q.r �I9'I (� � r^(+ Q CITY_ /��^i� Q,i STATE��ZIP SS�I3 a
PHONE: `%63�' S�G,— $ / S�
CONTRACTOR NAME:Ct'° • o� �X� '�
SUBMIT A COPY OF STATE LICENSE # aZO I�a c� 93 LEAD CERT NUMBER A�i¢T— a�I,3i /P /
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS:������"� CITY ,�j�-��11J STATE�%ZIP SS/d
INSURANCE PHONE O.S� FAX
PROPERTY TYPE Jg,SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRL'CTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
INTENANCE/REPAIR ❑ REMODELING
P
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
R OFIN ❑ HOUSE ONLY BASEMENT REMODELIN MIT�
NUMBER OF SQUARES ❑ HOUSE & GARAGE l. 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 pgo�t ADDITIONS & PORCHES SUBMTT�
❑ 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 S
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATinN � R�.`i 1"'� nrrTTn�rr�v TVDT.
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
� t lf�" I t L J See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ � .0005 x Permit Valuation Minimum $5.00
$ �j bQ $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 ( )
$ C�i L��— Make checks payable to: City 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 and codes f he City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application f p wor is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of k h' re i s view and approval of pl �,/ �
SIGNATURE OF APPLICANT NAME !�' "!� ,���.�LDATE
APPROVAL INSPECTOR SIG