P - 48570Building BUILDING Permit Ivo.: �dI Z' 3
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vate
763-502-4977 FAX �� ��
r� EFFEC"ITVE 1-1-2012
DATE J>' � L� 2- YOUR E-MAIL ADDRESS ✓�!\� c c w� �(� �� C�o �; L-0 y�,`
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THIS APPLICANT IS: �AAWNER �CONTRACTOR
PROPERTY OWNER/ NAME: �l tI�dLCc- °'
TENANT ' � ��y w'�ZN`�
ADDRESS. �i `-«'1 t� c fz ��� u- P,LV p ci�_ F� � v�� STATE iMIJ ZIP 5S �F '3-�
PHONE: _ `��� ZZ"Z --'S3'7� (�
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
STATE LICENSE # LEAD CERT NUMBER EXP:
ADDRESS: ..__ _
SINGLE FAMILY/NEW CONSTRUCTION
TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH �LROOF V
❑ DECK ❑ SIDING
u 5w1MMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION 0 ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODEL:
DESCRIBB WORK BEING DONE: . �(�o%E' � ���,� j�
SIZE OF IMPROVEMENT LENGTH �ry�I
R OFING ❑ HOUSE ONLY
NUMBER OF SQUARE '5��� ❑ HOUSE & GARAGE
ARA ES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
ATE ZIP
FAX
SIZE
STORI]
❑ DRAIN TILE
❑ OTHER
BASEMENT REMODE IN S MIT�
L Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑Soffit SIDING/SOFFIT/FASCIA ADDITION & RC S MIT
❑ Trim REMOVED? O YES O NO �• Site Plan/Survey showing the existing structures
❑ Fascia and proposed project.
WINDOWS 2• Two sets of construction plans
IN EXISTING OPENINGS ❑Yes �No LOCATION OF WINDOWS 3. Energy Calculations
OR FOR NEW OPENINGS-DESCRIBE SIZE OF FOR WINDOWS — PROVIDE U-VALUE AND
OPENING CHANGES & MANUFACTURE ST'ICKER ON WINDOW.
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 S ,,,.,-..,,. . �,.... -_ __ _
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
� /�GJ. L� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
� � S .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: Citv of Fridlev eff9��
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 all work w ic ec�ui es review and approval of pl,�?s. ,.
SIGNATURE OF APPLICANT ��d PRINT NAME V V�o�-� �[— �a Zaa�� DATE ?I' -( ��- ( 2,.
APPROVAL INSPECTOR SIGNANRE