P - 48089Bulldillg $jJjj,�IN(i PermitNo.:�� � `� ��
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vate��: �� �� ���
763-502-4977 FAX
EFFECTIVE 1-1-20ll
DATE I YOUR E-MAIL ADDRESS �� '(�P(l ��� ��S �'[y�y 'j7��LC��')
-- �
SITE ADDRESS I
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: ��� � lt
TENANT ADDRESS:IQ�DO IQ2A l.l.t/✓ CITY �. .�`�
� { � ���STATE IA _ZIr�y3,2
PHONEV%Ip�' ylj�}�
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # O ei`%� LEAD CERT NUMBER � AT "
YOUR STATE LICENSE � �I����I�"�� �
AND CERTIFICATE OF ADDRESS:��� (���� U E CITY STATrI�v ZIP��j►�! .�e?
INSURANCE pyONE (O ^ ^ �I FAX � �p
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
O DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: NEW HOME CONSTRUCTION ❑ ADDITION
INTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES � �HOUSE & GARAGE ]. 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 ❑Yes ❑No 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
ALLrL�L�JAKr.IfAaL�LVI� VALUAI1ViV�1PIl:LUL11VCi lHr:(;V�1 Ur LAIfUKA1VllMA1L�;KIALJ:
USING E 1Q .B C FEE SCHEDULE)
TOTAL JOB VALUATION OCCUPANCY TYPE
Permit Fee $ �. 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 $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Chazge $ Agreement necessary O Non Necessary O
Total Due $ �"�� 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 o ll work whi � re uires.�eview and approval of pl s.
SIGNATURE OF APPLICANT ������(�� ��e,1 I-� -��Q:71 iI CQ bj DATE � � m�, / I
�PRINT NAME �_
APPROVAL INSPECTOR SIGNATURE
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