P - 39988_v,
Building BUILDING Permit No.: °'
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vate xec'c1:
763-502-4977 FAX EFFECTIVE 1-1-2011
DATE St� IS , 2b� l YouxE-MniLnnn�ss Renee 1. � u�d � hatmai,!ca�,-,
s�TE �D�ss d 0 t le Haekmc n C � r IV�
THIS APPLICANT IS: �OWNER OCONTRACTOR
PROPERTY OWNER/ NAME:�{'�Q� �@� �r�C�.
TENANT ADD�ss: 101(� Ha�rw�a nn �«' N E ci� Fc�d��e.0 sTA�� zir SS
PHONE: � O I'�L-�-l� �i 3 y �
CONTRACTOR NA�v1�:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LF.AD CERT NiJMBER
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCI'ION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GA�GE/S�n vViNnows
❑ BASEMt;NT FRJISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCT'ION ❑ ADDITION
,,�fAINTENANCE/REPAIR ❑ REMODELING
DESC�BE wo� BE�G Do�: Reatac inG (��Ci W InL�OWS
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & Gt1RAGE BASEMSE.IV'P REMODELING SUBMIT:
1. Existing Floor Plau
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of strucKural membecs to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vuryl �Sofiit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ T� 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia � and proposed project.
\,�',i _ W� n 2. Two sets of consttuction plans
WIlVDOWS `�C ��� 3. Energy Calculations
IN EXISTING OPENINGS �Yes ONo LOCATION OF WINDOWS V� nY' W��S FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE S1ZE OF MANUFACTURE STICKER ON WINDOW.
OP�TIING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL N'1:L�'.�' AKL I3ASL�'ll UN VALUA'1'IV1V,1N(;LUll1N(i '1'HL�' (:U.�"1' Ul� LABUK ANll MA"1'L�'itIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Conirol
Park Fee
Sewer Main Charge
Total Due
�jOOO OCCUPANCY TYPE
$ ��, 2�'j See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuarion Minimum $5.00
$ $5.00 (State Licensed Residentiat Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ , s Make checks payable to: City of Fridle_y Attac
THIS IS AN APPLICATION FOR A PERMI I'-NOT VALID UN1IL PROCESSED
I hereby apply for a building permit and I aclmowledge 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'ji rmit and ork 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 work wh� ues review and approval of plans.
SIGNATURE OF APPLICANT ������ y, .,� PRINT NAME DATE
NOTE: SEPARATE�RMITS ARE REOtJIRED FOR
la �v-°
WORK