P - 48670Building BUILDING Perrnit rTo.p�..� �d �U �
Inspections RESIDENTIAL APPLICATION Received By: �l�
763-572-3604 CITY OF FRIDLEY vat��d!� �� �����
763-502-4977 FAX EFFECTIVE I-1-2012
DATE � � � YOUR E-MAIL ADDRESS ��-s �'t �{o°'� �S � G� `�' �• �d�
SIT'E ADDRESS % 3�� d� �'� S- �E
THIS APPLICANT IS: � OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: � �i�''� �� �/CE�v��-
TENANT pDDRESS: �3i �' C�'��° �" el/� CITY �.- t��Gy/ STATE ZIP
PHON$: �D�a � 7 ��' 77 � --�
CONTRACTOR NAME: ���5 �x �^��S — i3.:�-, �.d �f S
SUBMIT A COPY OF STATE LICENSE #� �3� 5�� LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: g�f)U �/'er�C' `4�^2 CITY %rG -N� STATE��ZIP SSs'S
INSURANCE PHONE �j�' %%� 3 c� � 7 FAX 76 3- y%� -� oc� q
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STOffiES
PERMIT TYPE � �DIT'ION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
� DECK ❑ SIDING � OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDIT'ION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: ✓�C� od
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 GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCfiON INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS. & 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 DYes ONo LOCAT[ON 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 N'L�'1;S AIiL�' BASL�'ll UN VALUA"l1VN,1NCLUll1NG "1'HL+' CV�"l� VN' LASUK ANll MA7r:K1ALJ:
(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
$ �C�'� 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 determinarion)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ , J Make checks oavable 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 City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application a permit 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 rk u'�re�view and approval of pl ��S L,/_�G` j�
SIGNATURE OF APPLICANT. PRINT NAME �/> c�., G�� DATE <
APPROVAL INSPECTOR SIGNANRE