P - 48547Building BUILDING Permit No.: � �' '�(�
Inspections RESIDENTIAL APPLICATION xe�ei�ed By: �, �
763-572-3604 CITY OF FRIDLEY Date��,�d: °= � u i
763-502-4977 FAX EFFECTIVE 1-I-2012
DATE ;l -- `� f Z YOUR E-MAIL ADDRESS
SITE ADDRESS r ""��� �ZZ Ci �- , ^ � �
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THIS APPLICANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: ,�1 ! L�i � �
TENANT ADDRESS: Z2v ( /'
C� Y J"� �� CITY__7-r/`J L� 7 STATE ZIP
PHONE:
CONTRACTOR NAME: (� , �n j�
SUBMIT A COPY OF STATE LICENSE #�. �
YOUR STATE LICENSE 3�U ��� LEAD CERT NUMBER Sf yd /�1 t�' /�'I EXP:
AND CERTIFICATE OF ADDRESS:f 3��' S� Gi. z?� � G� ,� � CITY �j G%yl1G���' STAT %rLIP `-�,� �J7
INSURANCE PHONE Z � � / �j �— � c� � FAX
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK .�.SIDING ❑ OTHER
❑ SWIMMING POOL
TYRE OF WORK: ❑ NEW HOME CONSTRUCT'ION O ADDITION
AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: S/ �%�"� �i �h I��° �Z f� j��
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE �. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SiDiNr FOR NEW CONSTRUCT'ION INCLUDING DECKS,
nyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO � Site Plan/Survey showing the existing sttuctures
❑ 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
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS•
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
(USING THE 1997 U.B.0 FEE SCHEDULE)
�i4 L � OCCUPANCY TYPE
$ C� �, j.. `� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ � 6v .001 times the total job valuation
$ � c�L .0005 x Permit Valuation Minimum or .50
$ G���,� $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to NIWCC 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 Fridley Attach Sti
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 only an application for a perm t 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 all� w'� r�� uires�uiew and a roval of 1 ns. / L y�_� Z
SIGNATURE OF APPLICANT 1 �` PRINT NAMEp� �6L�c yr"�''IJ�'h DATE �
APPROVAL INSPECTOR SIGNA [J�—'�