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Building BUILDING Pe�it Ivo.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vate Rec'd: �'o �
763-502-4977 FAX EFFECTlVE 1-1-2012
DATE I Z YOUR E-MAIL ADDRESS I� vl i'Y1 ca I/ ,�.�C'�_�S %� � Cv
SITE ADDRE S
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY OWNER/ NAME: G" �. �,�1�,.
TENANT ADDRESS: %�(, I�,GVI✓I lLift'Jrl. 1/y IUFCITY �V /eL �cQ� STATE�nZIP �
PHONE: 7G,� ^ -r�rJ�'U[76�
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CONTRACTOR NAME: '►-
SUBMIT A COPY OF STATE LICENSE # S� I a LEAD CERT NUMB R A'� E: I�Y ?i
YOUR STATE LICENSE ��-
AND CERTIFICATE OF ADDRESS: (��i ,�^���.t �✓ • CITY 1L % STATE�ZIP�
INSURANCE PHO 2'- G— I�- � FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION �❑ GA�� E/SHED INDOWS �f�'
❑ BASEMENT FINISH �'RWF ❑ DRAIN TILE
� DECK ❑ SIDING ❑ OTHER
� SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING � � HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES � ❑ HOUSE & GARAGE ], Existing Floor Plan
GARAGES � AT'fACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GAR�AGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCT'ION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT.
❑ Aluminum ❑ Trim REMOVED? O YES ❑ NO 1. Site P1an/Survey showing the existing strvctures
❑ Other ❑ Fascia and proposed project.
2 t � r s f r iv'� 2. Two sets of construction plans
WINDOWS 3�� � � 3. Energy Calculations
IN EXISTING OPENINGS es ❑No LOCATION OF WINDOWS � FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF �l I x�E Si n �rtiw es C�°j �� MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES AKE BAtiEll U1V VALUA'1'1VN, livC:LUUIIVC� ltl� 1;V�1 Vr La�svx aNli NiAi�xiaL�:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.00l times the total job valuation
.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 ( )
Make checks uavable to: City of Fridley Attach
THIS IS AN APPLICATION 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 applicatio or a pe i and 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 11 ork w re ires re ' w and approval of lans. �� Z_
SIGNATUREOFAPPLICANT TT PRINTNAME�n ���✓�i.trYley����ATE :Z.0 �
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