P - 36720Building BUILDING Permit No. � � -Q� .�
Inspections RESIDENTIAL APPLICATION lzecei�ed By:
763-572-3604 CITY OF FRIDLEY Date Rec'ct: �
763-502-4977 FAX EFFECTIVE 1-I-2011
DATE � 1 D` ( I YOUR E-MAIL ADDFtESS
SITE ADDRESS �' ZD �-s/�aid,Q,hp� r-
THIS APPLICANT IS: �OWNER ❑CONTRACTOR
PROPERTY OWNER/ N,�vIE: � �
TEI�TANT ,qDDRESS: j I � -�W �.v� .�
C�W �,_��, J�"c1' CITY I STATE � ZIP� y,3 Z—
PHONE:�� S%Z, �a�Z
CONTRACTOR NqME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE L[CENSE # LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ ARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF O DRAIN TILE
❑ DECK ❑ SIDING O OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCT(ON ❑ ADDITION
.�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: —� Yi�O � n
SIZE OF IMPROVEMENT LENGTH WiDTH HEIGHT S FT
ROOFI1�iG p HOUSE ONLY
NUMBER OF SQUARES � ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
__,_ I. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of swctural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION tNCLUDtNG DECKS,
❑ Vinyl ❑Soffit ADDITiONS. & PORCHES SUBMIT:
O Aluminum O Trim (• Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of conswction 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 r��s Ax�; �3ASED u1v vALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
�U� 1��HE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ w��� 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
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See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$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 ( )
Make checks payable to: Cityo uf Fridle_y Attach
THIS IS AN A�PLICATION 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 tart without a permit on site; that the work wilt be in accordance with the
approved plan in the case of all rk.whic uire revie an proval of!� ns. s.— �O ,
SIGNATURE OF APPLICANT _ _ �` M :N�E�gi� � �� _� pATE ��