P - 35753Building
Inspections
763-572-3604Y
763-502-4977 FAX
DATE % /! !/ �
SITE ADDRESS 7 �
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECITVE 1-1-2010
YOUR E-MAIL AD RESS
,� I� I c
THIS APPLICANT IS: 0 OWNER �CONTRACTOR
PROPERTY OWNER/ N,�: �GJ
TENANT pDD�SS: / ,cL �dJ N
PHONE:
CONTRACTOR
SUBM[T A COPY OF
YOUR STATE LICENSE
AND CERT'IFICATE OF
INSURANCE
PROPERTY TYPE
PERNIIT TYPE
TjrrE oF wo�x:
DESCRIBE WORK BE1NG DC
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES _
GARA ES
PROPOSED SIZE;
PROPOSED HEIGHT:
Permit No.: ���� � �
Received By: " �
���c��� �_. �
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'A%` ���ZIP
NAME: �/L�CGC-�T�'i� UI �l�i��G� J�� �` JOIo 6 lL-
STATE LICENSE # EXP DATE
ADDRESS; 3 9 38 ,��,�t�dt�tl�tS/Z�� � CITY .STI-[�.[J TA � IP�y��
rxo �e'�_ 9 3 3 �3 �7b Fax
INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES /
q BASEMENT FIDtISH ❑
❑ DECK ❑
❑ NEW HOME CONSTRUCTION ❑
❑ MAINTENANCE/REPAIR .�i
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑ DRAIN TILE
� OTEIER
HEIGHT
�ASEMENT REMODELING SUBMIT:
1. Existing Floor Pian
2. Proposed floor plan
3. List of structurai members to be used
ING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soff'it ADDTTIONS. & POR�HES SUBMIT:
����� ❑ Trim i. Site Plan/Survey showing the existing struchues
❑ Other ❑ Fascia and proposed project
2. Two sets of construcrion plans
WINDOWS � � 3. Energy Calculations
IN EXISTING OPENINGS BYes allo L �iTON OF DOW q FOR WINDOWS — PROVIDE U-VALITE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF .,(i � /�� � T� �f! MpNUgpCTURE STICKER ON WIlVDpW.
OPENING CHANGES &
TYPB OF WINDOW TO BEINSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE CO5T OF LABOR AND MATERIALS:
(iJSING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION $ %G�I7°° OCCUPANCY . 7�vpF
Pernut Fee
Plan Review
Fire Surcharge
Surchazge
License Swcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Chaz�e
Total Due
� S See Back Page for Fee Schedule
$ 65% of Building Pernut Fee
� .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ .S ° $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ tt+6ft= ftx$22=$
� $450 Conservation Plan Review
$ Fee Determined by Engineering
$ � Agreement necessary ( ) Non Necessary ( )
/ Make checks pa able to: City of Fridley Attach
THIS IS 41N APPLICATION FOR A PERM�T-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information abave 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 ' o start without a pernut on site; that the work will be in accordance witYi the
approved plan in the case of all work hich requir re '�nd approval of plans.
� u���,� � %
SIGNATURE OF APPLICANT ^�/J�l�i — PRINT NAME S� O'fI � !/�/�✓ DATF. �J /%1 J)