P - 36955-
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Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date ��! ���Q
763-502-4977 FAX EFFECTIVE I-1-2011
DATE YO R E-MAIL ADDRESS
SITE ADDKESS � ' � e i�'� �
THIS APPLICANT IS: ❑ OWN6R �(CONTRACTOR
PROPERTY OWNERJ NAME: C C d �
TENANT ADDRES3: { CITY ��I C� STATE�ZIP
PHONE: O
CONTRACTOR NAME: �
SUBMIT A COPY OF STATE LICENSE #�����r�AD CERT NUMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: ' CITY STATE ZIP
INSURANCE PHONE + FAX
PROPERTY TYPE �STNGLE FAMILY/NEW CON Q SIZE
❑ TWO EAMILY/1dEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGElSHED ❑ WINDOWS
O BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK [] SIDING O OTHER
❑ SWIMMING POOL
TYPE OF WORK: � NEW HOME CONSTRUC7'ION ❑ ADDITION
�MAINTENANCF/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: C�C
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
R FING ' ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES� O HOUSE & GARAGE
i . Existing Floor Pian
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTTON INCLUDING DECKS,
❑ Vinyt ❑So�t ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other � Fascia and proposed project.
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 MANUFACTURE STiCKER ON WIND(?W.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION S%Z �'D. � OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Chazge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
$ .,� ���_ See Back Page for Fee Schedule
$ �'!� 65% of Building Permit Fee
$ .001 times the totai job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ �- Agreement necessary ( ) Non Necessary,( )
$ v"Iri� 110.�1 — Make checks navable to: Citv of Fridiev Attach
THIS 1S 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 application for a permit and work is not to start without a permit on site; that the work will be in accordance with the
a roved lan in the case of 1 w��.w-hic re uires review and a roval of s. �,�,` � i
SpGNATUREOFAPPLICANT S,y/� � PRINTNAME�`QTIp�� �CIS�� AATE (() � I � I
APPROVAL INSPECTOR SIGNATURE