P - 48510Building BUILDING Permit No.:;:��v ��ii '''� ���
Inspections RESIDENTIAL APPLICATION Received By: �`t `��
763-572-3604 CITY OF FRIDLEY Dat���e`�' c1:� � F� 0' 7(� �
763-5f1�-4977 FAX EFFECTIVE 1-I-2010
DATE� _I - / '- � � YOUR E-MAIL ADDRESS
SITE ADDRESS I S`� 1 IV . O � 1Ct-J I�� Cl �C1L L / V`, F�� ��Z(� � I�11 � S5 � 3��
THIS APPL[CANT IS: ,�WNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: �T��-C I W�t L I(�j
TENANT ADDRESS: rJ� CC ���- / CITY STATE ZIP
PHONE: �� � '- � t % � � �(>V
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # EXP DATE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE p p��___ FAX
PROPERTY TYPE INGLE FAMI /NEW CONSTRUCTION SIZE
Y/NEW CONSTRUCTION STORIES o'L.
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH � ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING �OTHER /�� (� � �1�,,
❑ SWIMMING POOL � � W � W ��� (U(��
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR MODELING
DESCRIBE WORK BEING DONE: I N S( i� � I O � � KE.:.S �� N � - J W� O
SIZE OF IMPROVEMENT LENGTH WIDTH �O � HEIGHT 7��� SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELWG SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members ro be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCT[ON INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS, & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existmg 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 BAS�D ON VALUATION, INCLUDING THE COST OF LABUR ANll MA'1'�:K1AL5:
�� SINGrTH�E 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ ,-°� _)+!� : 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
$
$ y°'a � �
$ �-,�e
$
$
$
$
$
$
$ �t `i ` :sie;
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$2100 per SAC Unit (Plans to MWCC for determination)
�+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks payable to: City of Fridley
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
Attach Stioulations
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 1�ork,which re ' es review and approval of plans.
SIGNATURE OF APPLICANT L'� C�- � PRINT NAME �`'� � R(C I Y� ��( Iv DATE �� ! r� O
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