P - 39805Building BUILDING Permit rio.: b�
Inspections RESIDENTIAL APPLICATION Received By:
7f 3-572-3604 CITY �JF FRIDLEY ��'�e�� V � 2010
763-502-4977 FAX EFFEC�rvE �-�-zoio
DATE ,�� " i�'I "� � YOUR E-MAIL ADDRESS
SITE ADDRESS �� L�� tc � j� +'"� �
THIS APPLICANT IS: � OWNER ONTRACTOR
PROPERTY OWNER/ NpME: ,, Ne� �
TENANT ADDRESS:G+� ��.�_ i"� CITY �'"r� STATE�`"�'�ZIP SS %.3�
PHONE:
CONTRACTOR NAME: ,.� :�i� ri�-t�`e.� � �r � L�- �---�
SUBMIT A COPY OF STATE LICENSE # �� �$O � EXP DA �'I ��
YOUR STATE LICENSE ��, f�`t M, Ip �
AND CERTIFICATE OF ADDRESS: 0„��e� ,�5 2 C�_ CITY ��-, STATE �
INSURANCE pH NE `�C4 '— °% �`"`-' � 7 FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/[QEW COI�ISTRUCTION STORIES
PERMIT TYPE ❑ ADDI7'fON O ARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH � ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
Q SWIMMING POOL
TYPE OF WORK: Q EW HOME CONSTRUCTION ❑ ADDITION
AINTENANCE/REPAIR U REMODELING
DESCRIBE WORK BEING DONE: t—
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT 3Q FT
ROOFING n,�'^ � HOUSE ONLY
NUM$ER OF SQUARES v4J ❑ HOUSE & GARAGE BASEMENT REMODBLING SUBMIT:
1. Existing Floor Plan
GARAGES � ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: O DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUC710N INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of constTUCtion plans
WINDOWS 3. Energy Calculatiotts
IN EXISTTNG OPENTNGS ❑Yes C7No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEL�'S AKL�' BASL�'ll VN VALUAI'IUN, iN(:LUU�NG '1 HL�' (;V51' UN' LAtSUK AIVll MA L�K1ALa:
(USING THE 1997 U.B.0 FEE SCHEDULE)
JOB VALUATION S 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
$ �''( L`�, See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ t�, .001 times the total job valuation
$ I;'j, .0005 x Permit Valuation Minimum $.50
$ `' ���7 , $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ � Make checks navable to: Citv 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 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� ' h uires review and approval of plans. .
.
_..._ _ PRINT NAME '�� DATE I� U / O
SIGNATURE OF APPLICANT �� ;