P - 84299Building BUILDING Permit No.: �d� L `
Inspections RESIDENTIAL APPLICATION Received By�'�
763-572-3604 CITY OF FRIDLEY Da ,�Q�
763-502-4977 FAX EFFECTivE i-i-ZOi2
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DATE ��L3 ��_ YOURE-MAILADDRESS �¢'�'iCn �'�' �Y�/l�S-�j"'�'
SITE ADDRESS Lv.
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY OWNER/ NAME: � �'�vc� zv�
TENANT ADDRESS: � ` CITY ' STATE �1N ZIP �S�"I�2
PHONE: �lo , " 7$��0 ' �2-a �
CONTRACTOR NA,�:��'�,s�,,� �� �,.,1,��.�,.,�
SUBMIT A COPY OF STATE LICENSE #(�' .(�, I 2 � LEAD CERT NUMBER L� Jv�=S `� EXP:
YOUR STATE LICENSE ° �
AND CERTIFICATE OF ADDRESS: (A) __ Lh _.� _CITY � STATEl�ZIP SS�1�'l�
INSURANCE pHONE '� �. FAX
PROPERTY TYPE �SINGLE FAM LY EW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �OOF ❑ DRAIN TILE
O DECK � SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:� I�L�UY
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �_ �-HOUSE & GARAGE 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:
FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDING ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soff`it SIDING/SOFFIT/FASCIA 1. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No 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 FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Swcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
THE 1g37 U.B.0 FEE SCI�EI3Ui.E)
OCCUPANCY TYPE
$ "
$ �$
$
$
$
$
$
$
$ �.� _ �7
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 far 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 des 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 pe it 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 w' uires review and approval of pl s.
SIGNATURE OF APPLICANT PRINT NAME �,�i�_�Uti.-� DATE �� I2� � I2-
APPROVAL INSPECTOR SIGNA