P - 83515Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vate Rec'd:
763-502-4977 FAX EFFECTiVE 1-1-2012
DATE YOUR E-MAIL ADDRESS
SITEADDRESS %��.�j �L�tr$'oti (.(ia�/ � �'/'i��. %lAN $Sy�Z
THIS APPLICANT IS: �OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: Ci' �Z f�r �7�Srl�/1
TENANT ADDRESS: %� S %�r�i r� � CITY �-rr� ty STATE�ZIP SS�/3Z
PHONE: %� �-- � % 2 - ?j a O (
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER EXP:
AND CERTIFICAT'E OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE gq}{
PROPERTY TYPE lj�i SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ 'TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK � SIDING I& OTHER
O SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ADDITION
❑ MAINTENANCE/REPAIR '�.REMODELING
DESCRIBE WORK BEING DONE: I� i 7� k t h F^ t N. a t�t �� /�t.ti,n.t. keK s� I1e.ew..� �a (( ,
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SL7F3MIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 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/FASCIA �DITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? � YES O NO �• Site Plan/Survey showing the existing sWctures
❑ 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-VALLTE 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 TI�E 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ _!'/� (9O, OCCUPANC�7�tir4 F�w%ly TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$ �
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 determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
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 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 is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of al�V oilc w�Ch requ eview�iid approval of pl�r►s. 3� r-�
SIGNATURE OF APPLICANT Y1�-7i � 1„ ��4./� pRITIT NAME (;�/`,L (�, �p`vi�Sd�1 DATE �!'` �`
APPROVAL INSPECTOR STGNATf iRR
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