P - 84360Building BUILDING Permit No.: �I�1't%18(��'"
Inspections RESIDENTIAL APPLICATION Received -���' ,. - , �.
763-572-3604 CITY OF FRIDLEY ��eo���~�F����
763-502-4977 FAX EFFECTIVE i-1-2012
DATE � �"Z " � YOUR E-MAIL ADDRESS
SITE ADDRESS % `rts/��,� QP'
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: � ,f0 i"
TENANT ADDRESS: �..3 %% �j�jf/��f Q/', CITY r �T STATE ��GIP �J
PHONE: %�r� %�� ���'�_
CONTRACTOR NAME: G tS d�, ' 7�
SUBMIT A COPY OF gTATE LICENSE #�-� G,�'S � LEAD CERT NUMBER EXP:
YOUR STATE LICENSE i
AND CERTIFICAT'E OF ADDRESS: ��-� �.3 (3r�rH7 fT. CITY �F/q.s, Lc.Gc STATE.�f�, IP�
INSURANCE PHONE /�.,�f � �l FAX
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTTON SIZE
� TWO FAMILY/NEW CONSTRUCI'ION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ 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 SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NiJMBER OF SQUARES � ❑ HOUSE & GARAGE ], Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARq1GE 3. List of structural members to be used
PROPOSED HEIGHT. "
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITTONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO I. 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 ONo 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)
OCCUPANCY TYPE
$ ,;� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ � .001 times the total job valuation
$ / t .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 ( )
$ � Q 7,�,(� Make checks payable to: City of Fridley 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 Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit 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�}''� r�k �- �ch requires review a d approval of plans/�� 6 4�j
SIGNANRE OF APPLICANT ���"T� � PRINT NAME /+./��� %,�<Q�y � DATE I� G�-'"� Z—
APPROVAL INSPECTOR SIGNATURE �— �"