P - 36964�
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Building
Inspections
763-572-3604
763-502-4977 FAX
DATE 1 Li '
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLE�
EFFECTNE 7-I -2010
❑ OWNER
ADDRESS:
YOUR E�-MIAIL ADDRESS
� /V�
�ONTRACTOR
CONTRACTOR NAME: A-I ilU - U� �� 1 Nl..,
SUBMIT A COPY OF STATE LICENSE # S�I I I
YOUR STATE LICENSE
AND CER'TIFICATE OF .4DDRESS:
INSUiZANCE PHONE
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
PERMIT TYPE � �DTTION ❑ GARAG
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ SWIMM
TYPE OF WORK: ❑�EW HOME CONSTRUCTION
��I /l.0 CITY L �
EXP DATE
� /� i CI1'Y�
FAX
SIZE
STORIES
iISHED DOW3
❑ DRAIN TII,E
❑ OTHER
NG POOL
❑ ADDTfION
� REMODELING
Permit No.:
Received
D�6���'
ATE MJU ZIP.
DESCRIBE WORK BEING DONE: V�,�( l�l.C7"lL/� l `V //l.!/lJ'✓,1
5IZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY ' BASEMENT REMODELING SUBMIT•
NUMBER OF SQUARES ❑ HOUSE & GARAGE
1: Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor pian _
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT: _
FOR NEW CONSTRUCTION INCLUDING DECKS,
5IDING A�DITIONS & PORCHES SUBMIT•
❑ Vinyl ❑Soffit 1. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim and proposed project.
❑ Other O Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN E�{,ISTING OPENINGS OYes ❑No ` LOCATION OF WINDOWS FOR WINDOWS — PROViDE U-VALUE AND
OR FbR 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 MATERIAL5:
,,�SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 3�`�l� ' OCCUPANCY TYPE
Permit Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ 0 .001 times the total job valuation
Surc�iarge � .0005 x Permit Valuation Minimum $5.00
License Surcharge $ `,�`� $5.00 (State Licensed Residenrial Contractors)
SAC Charge $ $2100 per SAC Unit (Plans to MWCC for deternunation)
Curb Cut Escrow $ ft+ 6 ft= ft x$24 =$
Erosion Control $ $450 Conservarion Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary (} Non Necessary O
Total Due $—��i i�i.� �Make checks payable to: City of Fridley Attach Stip�lations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSEA
I hereby apply for a building ermit d I aclmowledge that the information above is complete and accurate; °that the work will be in
conformance with the ordi ce an c es of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an appli tion r p ' and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the c of all ires rev' proval of plansy�, p� �/
SIGNATURE OF APPLIC _ PRINT NAME ✓LJ H 1V � J�J (�l, DATE