P - 37820Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By: (I
763-5.72-3604 CITY OF FRIDLEY Da���' :�� .�
763-502-4977 FAX EFFECTIVE 1-1-2011 �'"
DATE ! rI YOUR/� -MAIL ADDRESS
SITE ADDRESS _ `L�8' U QG']Z t77.J �jT• /j/�` �` /��'�,�� �t.jr//
,�T
THIS APPLICANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME:_�Q 0����,
TENANT pDDRESS: L- �> CITY����/ � STATF./"I�(/ ZIP
PHONE: Z� ' O • p �
CONTRACTOR NAME: I�W�� � L rc.Ji.�
SUBMIT A COPY OF STATE LICENSE #? O� �%�` � 2, LEAD CERT NLfMBER
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: ���Sl.errrl c� �S CITY p S STATE�'Jrl21P SSY�v
INSURANCE pHONE ' 21� �' (pI'Z FAX
PROPERTY TYPE $`1 SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ,�ROOF ❑ 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 �� L�
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim I. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calcula[ions
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON W[NDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL N�r;� AKr; tiA��ll VN VALUA'1'IUIV, 11VCLUll1NG "1'HE CUS'I' UF LABUR AND MATERIALS:
���5ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $� C' �`�t '� �3 I� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total 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 ( }
Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a buitding 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
approved plan in the case 'ch re uires review and approval of plan .
SIGNATURE OF APPLICAN PRINT NAME ��,�,..JV�, � C�� DATE S'�l —I �
APPROVAL INSPECTOR S[GN E