P - 62719^ �
Building BUILDING Pe�it r1o.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date Rec'ct:
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE % � �CJ '- � � �YOLUR E-MAIL ADDRESS
SITE ADDRESS �� Q�'l�,i'�✓t CyT
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: C, n �0�
TENANT ADDRESS: CITY STATE ZIP
PHONE:
CONTRACTOR NAME: vw ��'I c� v(w. vw�
SUBMIT A COPY OF STATE LICENSE #__ �CL�3� S I�P7 LEAD CERT NUMBER EXP:
YOUR STATE LICENSE � " ,r
AND CERTIFICATE OF ADDRESS: JY Se'l3 1,W; �`� c�- /(J� CITY /�i�+�+ C� �G< STATE !"��✓ZIP�
INSURANCE pHONE .1 ` yy3- � FAX
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITTON ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH '�ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMivIING 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
NUMBER OF SQUARES � ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GAR�AGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCITON INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? O YES O NO 1. Site Plan/Survey showing the existing structures
� Other ❑ Fascia and proposed proj�t.
2. Two sets of conshuction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �Yes ONo 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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ . See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ � .0005 x Permit Valuation Minimum or .50
License Surcharge $ ,� . $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2365 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ , 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 permi��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 ity of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for pe ' ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of ic r s review and approval of plan�;/'� ��g�/
SIGNATURE OF APPLICANT A°' PRINT NAME J��--� �►�'r�+'l DATE ti"�% ' I oZ
APPROVAL INSPECTOR SIG ' , eC