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g BUILDING Perrriit Ivo.: —C' �' � `1� ��
Inspections RESIDENTIAL APPLICATION Received By: ti�' �
763-572-3604 CITY OF FRIDLEY
763-502-4977 FAX � ���'-�� " �p�--�'�-
EFFECTIVE 1-1-2011
DATE YOU E-MAA� CADDRESS
SITE ADDRESS � � C �� �� 'V C�
THIS APPLICANT IS: ❑ OWNER � ONTRACTOR
PROPERTY OWNER/ NAME: ` l
TENANT
ADDRESS: CITY � �_� STATE� ZIP S�
PHONE:
CONTRACTOR N,�v1E:_ f'1-s�•,,�t„� i��Ks I...,.�I.�,. ��► �,u
SUBMIT A COPY OF STATE LICENSE # p-u � 3� S I LEAD CERT NUMBER
YOUR STATE LICENSE �1 �
AND CERTIFICATE OF ADDRESS: (��� � l�N�-� �- cS �- CITY N� � L�-�'-� STATE �^NZlP S S 3 tl t-t
INSURANCE PHONE � — 3 — (Q � Fp}(
PROPERTY TYPE ❑ SINGLE FAMILYlNEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH O ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING � OTHER
❑ SWIMMTNG 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 ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structurai members to be used
PROPOSED HEIGHT:
IDING FOR NEW CONSTRUCTION iNCLUDING QECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of conswction plans
WINDOWS 3. Energy Calculations
M EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WMDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WMDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING TIIE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
'�1,
- �i
s�
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�si��'
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: Citv of Fridlev
TH1S IS AN APPLICATION FOR A PERMIT-NOT VAL1D 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 fo it nd is not t start without a permit on site; that the work will be in accordance with the
approved plan in the case of e res eview d appro al of plans ?���� �`
SIGNATURE OF APPLICANT ___ _ PRi�NAME S� ��'�c-���_DATE J�3' I�