P - 84402Building BUILDING Permit rlo.: o�4f�}�0175�
Inspections RESIDENTIAL APPLICATION Received By: 1 r��
763-572-3604 CITY OF FRIDLEY D�d���'�� 7 2012
763-502-4977 FAX EFFECTTVE i-i-zo�z
DATE �C� f�7�J�" YOUR E-MAIL ADDRESS �N f Z.5' a2 y% � / jZO�, Go�,
SITE ADDRESS r'i ��,/ Or}/�/Q i/ S 7' �rr'�/�, � /j'1/�
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: �✓a �/
TENANT ADDRESS: � O177f S CITY �!^/ `�e f,/ STATE�iI ZIP �
PHONE:
CONTRACTOR NAME: �Jl1'�G /��+�s �'s, �
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER EXP:
AND CERTTFICATE OF ADDRESS: 1��� .2 � �v . Gc� CITYS�g.h f Fr..s•;�STATE�/GIPS�'07D�
INSURANCE pHONE �"� I" U� f FAX
PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE � S/�
TWO FAMILY/NEW CONSTRUCTION STORI S�_
PERMIT TYPE ❑ ADDITION � GARAGE/SHED O WINDOWS
❑ BASEMENT FINISH �'ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
MAINTENANCE/REPAIR REMODELING
DESCRIBE WORK BEING DONE: w
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT•
NLTMBER OF SQUARES �� �FIOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARQ,GE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vin I ADDITIONS. & PORCHES SUBMIT•
Y OSofrit SIDING/SOFFII'/FASCIA l. Site Plan/Survey showing the existing structures
❑ Aluminum ❑ Trim REMOVED. ❑ YES O NO and proposed project.
❑ Other 0 Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes 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
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ r/ /�_ See Back Page for Fee Schedule
$. 65% of Building Permit Fee
$ 1 .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 checlzs payable to: Cit.y 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 nit and ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o o• ires review and approval of p s. % L . 7
SIGNATURE OF APPLICAN '�' •v' PRINT NAME�/�/J yC,����1 �� DATE /U/� / f/� ,
APPROVAL INSPECTOR SI AN