P - 44940Building $jJII,DIN(i Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
�63-s�2-3604 CITY OF FRIDLEY vate
763-502-4977 FAX �E� �
EFFECTIVE 7-1-2010
DATE �I ��l1 1 � O n � YOUR E-MAII ADDRESS Q rI'�I i( l'( G� ��'t lU �..�5 h OlYi-� I' /l.�' +�' �`i /7'1
SITE ADDRESS I L
THIS APPLICANT IS: OWNER ��ONTRACTOR
PROPERTY OWNER/ N,�E;�.�--'�p �pi>p n�an •r �AL+h �„Q L�n1Y1 �
TENANT pDDRESS: ?i?J 2. ,�� 1( CC.0 . ITY �T� STATE�LIP <.�H 3'L
PHONE: ( D I'Z °� O O' I^] �
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
ROOFING
NUMBER OF SQUARES _
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
�^�� ��;��9:���re
STATE LICENSE
ADDRESS:�Ii' 1 i
{�,SINGLE FAMILY/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTTON
❑ BASEMENT FINISH ❑ ROOF
❑ DECK ❑ SIDING
❑ NEW HOME CONSTRUCTION
'�CMAINTENANCE/REPAIR
WINDOWS
IN EXISTING OPENINGS es ❑No
OR FOR NEW OPENINGS- ESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED�! �,
ALL FEES ARE BASED ON
AL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
EXP DATE �
�(.yl,e_�") I � CITY�- . �N
FAX (D/rL"�-� ,> >
SIZE
STORIES
;/SHED INDOWS
❑ DRAIN TILE
❑ OTHER
NG POOL
❑ ADDITION
❑ REMODELING
/i?�'G-�� ! yl d �'L-ef i �1.er�
WIDTH HEIGHT
❑ HOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
STATE�_�IP �1 �
BASEMENT REMODELING SUBMTT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
2. Two sets of construction plans
3. Energy Calculations
L CATI 1 OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
S• � i ,� "�(,-�L MANUFACTURE STICKER ON WINDOW.
J" ` p:U%�i
NUMBER OF W WS
ALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
USING THE 1997 U.B.0 FEE SCHEDULE)
GIS� OCCUPANCY TYPE
$ �7 �( �oZ 5 See Back Page for Fee Schedule
$ 65% of Building Pernut Fee
$ .001 times the total job valuation
$ � � .0005 x Permit Valuation Minimum $5.00
$ 5�6 $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Deternuned 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
� hereby apply for a building pernvt and I acknowledge that the information above is complete and accurate; that the work will be in
confonnance 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 s without a pemut on site; that the work will be in accordance with the
approved plan in the case of all work hic requ' review prov of p ns. Q
SIGNATURE OF APPLICANT PRIN /) �� S�� DATE
APPROVAL INSPECTOR SIGNATURE