P - 60276Building BUILDING Permit No.:�(� � E� �(�
Inspections RESIDENTIAL APPLICATION Received By: ��
763-572-3604 CITY OF FRIDLEY vat ' �� �
763�SO2-49%% FAX EFFECITVE 1-1-2012 ����
DATE LI '� �( d" YOUR E-MAIL ADDRESS
SITE ADDRESS ��I � � a� �
THIS APPLICANT IS: OWNER DCONTRACTOR
PROPERTY OWNER/ NAME: � f' �'� 5�^ � S--�-"
TENANT ADDRESS:G y�� �'� ��Y' 12� CITY �°� � �`{ STA1'@�") ZIP 5�� y3-2
PHONE: � i�- S°� b" `� �( a�
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER EXP:
AND CERTIFICAT'E OF ADDRESS: CITY STATE ZIP
1NSURANCE PHONE FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED O WINDOWS
❑ BASEMENT FIIVISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING � OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ RE OD ING
DESCRIBE WORK BEING DONE: �'� �� S w �^ ��+�.! � � � %
�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER 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 ADpITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES O NO l. Site Plan/Survey showing the existing structures
and proposed project.
O Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS Yes ❑No L CATIQN OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENING -DESCRIBE SIZE OF ��� T�. �'�-� �� `� � MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & ^�
TYPE OF WINDOW TO BE INSTALLEDC`�'SKK� �� NUMBER OF WINDOWS s�
�►LL r�,�;� Ax�: �s��;1� V1v vALUAl1Viv, llv(:LUU1PIt='1'H� C:VS'1' UN LASUR A1VD MAT'EK1AL5:
TOTAL JOB VALUATION $ 3� J�USING THE 1997 U.B.0 FEE SCHEDULE)
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
$ '�`Ji5(�' See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ � Q .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 ( )
$ j •� Make checks payable to: City of Fridle_y 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 of the City of Fridl and w' the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work is not s thout a permit on site; that the work will be in accordance with the
approved plan in the case Qf� all work w'c revie d app al of1 �ans.
SIGNATURE OF APPLICANT �?M--^- P NAME �.Ji'Cw J-� L. �l` S� `�� DATE �I y� � �,�
APPROVAL INSPECTOR SIGNATURE .G1' /d i�I