P - 48332Building BUILDING PermitNo.• v � '
Inspections RESIDENTIAL APPLICATION Received By: °
763-572-3604 CITY OF FRIDLEY Date ��c��� `���`�
763-502-4977 FAX EFFECTIVE ]-1-2012
SITE ADDRESS �j �' � YOUR E�-�M�/��IL� ADDRESS
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THIS APPLICANT IS: ❑ OWNER ��9CpNTRACTOR
PROPERTY OWNER/ NAME: �
TENANT ADDRESS:.J� Z�— �,�,-�5 Ipr i%L� L� CITY STATE ZIP
PHONE:
CONTRACTOR NAME: I i`� �-U I t� N�1 ✓t L��- C. GO �^�'/i✓< l��^ -% �'G
SUBMIT A COPY OF STATE LICENSE �. 4� Z) Z LEAD CERT NUMBER EXP:
YOUR STATE LICENSE J1
AND CERTIFICATE OF ADDRESS: L�[� G-G � e�^ Gl � C CITY(rG�j��� � Li� STATE/t9✓� ZIP,3�7Z�
INSURANCE pHONE �O%a� `��y' % r 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
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCEIREPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: �E 1ZvCr i I f�! �SC-
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING f� �-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 ❑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 ANll MA'1'ERIALS:
(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 O Non Necessary O
Total Due $ �. Make checks aavable 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 work ich req ' s review an approval of pla s.
� -M�.,--__.
SIGNATURE OF APPLICANT � PRINT NAME ���-%��, :.�. 1 P�iy �'� DATE��I�
APPROVAL INSPECTOR SIGNATURE