P - 46520Building BUILDING Permit r�o.:
Inspections RESIDENTIAL APPLICATION Received By: J
763-572-3604 CITY OF FRIDLEY vate��: �� v i o� e�
763–SOZ-49%% FAX EFFECTIVE I-1-2011
DATE /�—��'i / YOURE-MAILADDRESS G�►rtc� 3�t4�4� C�rY/I�r�
SITE ADDRESS � 7 yCj �U'f I��at� L7 R��ft.
THIS APPLICANT IS: ❑ OWNER [,�ONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
NAME: De u v� =S L n 1�Dc5i�
ADDRESS: CITY
PHONE:
ATE Z[P
STATE LICENSE # LEAD CERT NUMBER
ADDRESS: ,�� I� W fiibl� � l CITY �(K. �.i�tQ� STATE /✓K) ZIP 5�4`3 30
t'riVNb 1 l n'7 - nc.-�O ��G "!
�$INGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILYMEW CONSTRUCTION
FAX
SIZE
STORIES .
❑ ADDITION ❑ GARAGE/SH�u u wiNV�w�
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
LENGTH
FT
ROOFIIVG ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
� NUMBER OF SQUARES � ❑ HOUSE & GARAGE �. Existing Floor Plan
i GARAGES � ATTACHED GARAGE 2. Proposed floor plan
�i PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
' PROPOSED HEIGHT.
FOR NEW CONSTRUCTION iNCLUDING DECKS,
SI ING ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soffit 1. Site PlanlSurvey showing the existing structures
❑ Aluminum � Trim and proposed project.
❑ Other ❑ Fascia 2. Two sets of construc[ion plans
WINDOWS 3. EnergyCalculations
IN EXISTING OPENINGS ❑Yes 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
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ (��, 2��_ See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ �( .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $5.00
$ $5.00 (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ _ 6 Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and 1 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 wor is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of all wo review and approval of plans. � /f �
StGNATURE OF APPLICANT PRINT NAME G��K,-�'/ f1 ��`s� DATE �� lY��
APPROVAL INSPECTOR SIGNATU