P - 48613Building BUILDING Permit No.: d�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date xec'ci:
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE �°' � ip '— I�, . YOUR E-MAIL ADDRESS YY�'� '� � � ���� � CQ, ��l QG- � �) ��2�
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THIS APPLICANT IS: J�OWNER OCONTRACTOR
PROPERTY OWNER/ NqME:_ ►`VI C�S� �'1 G'l �[Gt`o� C
TENANT ADDRESS: L7S�� L'vC l G� G{1 N� CITY Fy � C���{ v� STATE���ZIP � �
PHONE: �l Z— S�O "��l G� 1.
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 �SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH .gI ROOF ❑ DRAIN TILE
O 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 SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NLJMBER OF SQUARES ��T ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ AT"fACHED 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,
❑ Vin ( ADDITIONS. & PORCHES SUBMIT:
Y ❑Soffit SIDING/SOFFIT/FASCIA �. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim REMOVED. ❑ YES ❑ NO and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALiTE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
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 $� 7�2NG THE 1997 U.B.0 FEE SCHOCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ��� � as
$
$ .
$ 02�
$
$
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 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 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�;mit nd 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 al r whi h�q ire,s r view and approval of plans.
SIGNATURE OF APPLICANT r L" (� PRINT NAME DATE
APPROVAL INSPECTOR SIGNA JRE " �� �,j✓1 ,'1.n "
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