P - 84306Building BUILDING Permit Ivo.: o� � tP
Inspections RESIDENTIAL APPLICATION xecei�ect By: ��
763-572-3604 CITY OF FRIDLEY vat
763-502-4977 FAX EFFECTIVE I-1-2012 ����`�� �
DATE '�� � � ' � � YOUR E-MAIL ADDRESS
SITE ADDRESS �� l �'/ Q d� \� ar
THIS APPLICANT IS: � OWNER CA�ONTRACTOR
PROPERTY OWNER/ NAME: � t� �� Cilc.� 1 I���� v�
TENANT ADDRESS: �''/ ��l � c�.-� � �_ STATE�z�p ��
� O✓ "\ CITY ��'.�
PHONE: �� l - ✓� �f.3, O� � � `-r
CONTRACTOR NAME: ��-�i i� uY. c"��v c.'�� u w
SUBMIT A COPY OF STATE LICENSE # �I 1' LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �/�_S� e� S� P � �% �� H CITY ��i 4 a, �'1 STATE�wZIP
INSURANCE pHONE G% U G LI ' FAX �
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ 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: �� ��CJ �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES 3� �-IOUSE & 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 CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCTA t1DDITTONS, & 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 ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STTCKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASEll ON VALUA"1'1UN,INCLUll1NG'1'HL CUS"1' UN' LAKUK A1Vll MA1N:K1AL5:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee $ 5 See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuation
Surcharge $ .0005 x Permit Valuation Minimum or .50
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2365 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Pian Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
Total Due $ l�l� -, 1 Make checks pavable to: City 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 permit and work i�ot to start without a permit on site; that the work will be in accordance with the
approved plan in the case of al work �zr :�. rPn,�:�""r" �ew and approval of pla . /�
SIGNATURE OF APPLICANT � --°-- . PRINT NAME �%� i�� � 5%�1 i35 /� l DATE � G'}� '� � Z_.
APPROVAL INSPECTOR SIGNAT[�� -T