P - 44352�b7.5S
Building BUILDING Permit No.: �u IL l„ �����
Inspections RESIDENTIAL APPLICATION Received By:�1r;�
763-572-3604
763-502-4977 FAX CITY OF FRIDLEY Date�: �� �� .� ���
EFFECTIVE 8-19-09
DATE �/�� �0 Y�OU1R E-MAIL ADDRESS
S[TE ADDRESS ' .1 pD (if�v�N �'�Q" `Dp" / v �
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NpME: q�'
TENANT ADDRESS: �'iO CITY f STAT Z[P �
PHONE: ^
CONTRACTOR NAME: �r1�A N�ir�l A�enw�� A1C
SUBMIT A COPY OF STATE LICENSE # EXP DATE ?' 37'I I
YOUR STATE LICENSE -
AND CERTIFICATE OF ADDRESS: , t1Q�l1 R'f�1_�M77 CITY STATE ZIP
INSURANCE PHONE . FAX %/Z " it S� 7
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCT'ION � SIZE
❑ TWO FAMILYMEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITTON
-B'I'OfAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:_ W�'� ��JS
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
F G ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NLJMBER OF SQUARES � HOUSE & GARAGE I. 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 ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum � Trim 1. Site Plan/Survey showing the existing structures
and proposed project.
❑ Other ❑ Fascia 2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS �fes ONo LO�'fON O INDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
�PENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED U NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUA ON, INCLUDING THE COST OF LABOR AND MATERIALS:
TOTAL JOB VALUA
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
VG THE 1997 U.B.0 FEE SCHEDULE)
Q''� OCCUPANCY
$ - —
$
$
$ �Z�
$
$
$
$
$
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)
$2000 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$22=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks payable to: Citv of Fridlev
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTlL PROCESSED
Attach
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 r a p it and work is not to start without a permit on site; that the wor will be in accordance with the
approved plan in the case of a k res review and approval of pla
SIGNANRE OF APPLICANT �'Y PRINT NAME I/V �"` V, �V ATE /~/a�I �/