P - 36679Building BUILDING Permit No.: b
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY 1�ate xec���� �`��� �
763-502-4977 FAX EFFEC7'IVE 1-1-2010
DATE � '� � � YOUR E-MAIL ADDRESS
SITEADDRESS O O L.�'i iP�E � �'C � lJGC�
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: /►�
TENANT ADDRESS:� S�� �� I+Mar-e- S'�' NF CITY_��i STATEM� ZIP �c.�3r-
PHONE: G 3 G �� � ��
CONTRACTOR NAME: � 6'�
SUBMIT A COPY OF STATE LICENSE #' 3�T �$ EXP DATE
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: (�(�I � C�J!.� I� �- CITY �%Mi�Brw�KLA�c�STATE / � ZIP [o
INSURANCE PHONE ��'"�d'`i �22-8� FAX - G"'
PROPERTY TYPE 0 SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION � GARAGE/SHED ❑ WINDOWS i
❑ BASEMENT FINISH, �tOOF ❑ DRAIN TILE
❑ DECK ❑ SIDING O OTHER
❑ SWIMMING POOL
TYPE OR WORK: ❑ NEW HOME CONSTRUCTION D ADDITION
❑ MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH ' WIDTH HEIGHT S FT
ROOFING ,�-k►OUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES � O HOUSE & GARAGE 1. Existing Floor Plan
S:ARAGES ❑ 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 ADDITTONS_ & PORCHES SUBMIT:
❑ Aluminum 0 Ttim 1• Site Plan/Survey showing the existing structures
❑ Other ❑ g�18 and proposed project
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXIST[NG OPENINGS DYes �No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPEAIING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATIUN, iNCLUDIN(G "1'HE CU.S"1' VN' LABUK ANll MA"1�1:K1AL.5':
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$ /. �i
$
$ �
$
$
$
$
$ _ ., ..
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$2100 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks �avable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UN7'dL 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 applicatio o a permit work is not to start without a.permit on site; that the work will be in accorclance with the
approved plan in the case of 1 wo which ir review and approval of plans.
,,�n �,(� �,y�, .��
SIGNATURE OF APPLICANT `� ` PRINT NAME '� F�C�I�-+ ^""'DATE � �� � � ` �
ii