P - 48565Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION xeceived By:
763-572-3604 CITY OF FRIDLEY vate Rec'ct: �� b�
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE �`� r' � YOUR�-MAIL A D SS /
SITE ADDRESS �D r.� S� NL� .� r � 3� Z
THIS APPLICANT IS: WNER , ❑CONTRACTOR
PROPERTY OWNER/ NAME: L ..�yy
TENANT ADDRESS: g 0 �a /� fa�I S�` '��� CITY ri '� STATE ZIP_���e1�L
PHONE: �I� � - Z 3°Z - S�S�GI� _ ` �
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE F�
PROPERTY TYPE SirrGLE FANnLYmrEw corrS�rxucTTOrr s�zE
❑ TWO FAMILY/NEW CONSTRUCTION STOffiES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING � OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION 0 ADDI1'ION
❑ MAINTENANCFJREPAIR � REMODELING
DESCRIBE WORK BEING DONE: �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING � �S HOUSE ONLY BASEMENT REMODELING SUBMIT�
NUMBER OF SQUARES � S❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: O DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
FOR NEW CONSTRUCTION INCLUDING DECKS,
5IDING ADDITIONS & PORCHES St�3MIT•
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim REMOVED? 0 YES O NO and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACNRE STICKER ON WINDOW.
OPENING CHANGES 8c
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BA51;D Viv VALUA11u1v, iN�;i.uliitvtJ inr, �.v�i vr LHDVA E11�i/ 1�1[i11�i1�it�a�U.
(USING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUA'
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
ANCY
$�4 ,�JS" See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ ,5 .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 ( )
� n.. Make checks aavable to: City of Fridley Attac!
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permi � and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and des 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 pe it 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 ork equ'res review and approval of plans_,�- �
SIGNATURE OF APPLICANT PRINT NAIvfE �bG rltiJ �/S�_DATE 3 r�✓� �—��