P - 62714•4
B(.�ilding BUILDING Permit No.��'�?1(.�(,�'�
Inspections RESIDENTIAL APPLICATION Received B: �
763-572-3604 CITY OF FRIDLEY ���:�` d���� ��
763-502-4977 FAX ���
EFFECT'IVE 1-1-2012
DATE � ` � '" I �' � y YOUR E-MAIL ADDRESS ✓��`►� �/_ � �`j�-(� � �-. �,"'YJ �L"�? G ti�;' t� (�.L�W1-
SITE ADDRESS j�� �� L 2l E:. dr'YV I"'� v' -� /�-�� `„ �{ (� u�
THIS APPLICANT IS: OWNER ❑CONTRACTOR
PROPERTY OWNER/ NA E: _,�-� c.-� ~ K f�V t;� i�!I�� :�,�,� �, `-�-'I'�-'
TE1vA1vT � ;�,�:c� �' XJ�ciTY ��-t.� C.-�= ' sTAr � �z[r ` a�3 ��
ADDRESS: /�S� C «E>.� �
PHONE: �^%G;9=% 5Il '"%S`7�-
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER EXP:
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE ❑ stt�rGLE F.atvtiLY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDIT'lON ❑ GARAGE/SHED WINDOWS
� BASEMENT FINISH ❑ ROOF ❑ RAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
� 'MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: L� i�"l �� (./ i� f���C.��L"f C���7�� /V / ���
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
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 SIDING/SOFFIT/FASCIA ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 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 es ❑No LOCATION OF INDOWyC FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE STZE OF ;/�? /�� MANUFACTURE STTCKER ON WINDOW.
OPENING CHANGES & - l����,,v /I
TYPE OF WINDOW TO BE INSTALLED •' NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
(USING THE 1997 U.B.0 FEE SCHEDULE) ,.,
��0i:'CJ � �`G7 OCCUPANCY � TYP
$ �
$ �Jy
$ � C��
$
$
$
$
$
$
$ 117'3. �
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum or .50
$5.00 (State Licensed Residential Contractors)
$2365 per SAC Unit (Plans to NIWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks navable to: Citv of Fridlev 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 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 of a� work which requires review and approval of p s. ,
SIGNANRE OF APPLICANT -v'_�'�-�� ��"y�� ��� ' 2��� PRINT NAME �+ i��r C� �' �'( pr 71 F��� cj DATE ��� ��=�
APPROVAL INSPECTOR SIGNANRE