P - 62697Building BUILDING Permit No.:?-� �Z�
Inspections RESIDENTIAL APPLICATION Received By:��''
763-572-3604 CITY OF FRIDLEY �° #� 20"�
763-502-4977 FAX �f� �. � 1 s
EFFECTIVE 1-1-2012
DATE �l ;' �.�'�� � �� 2--'- YOUR E-MAIL ADDRESS
SITE ADDRESS �'r/'�) �/1..�,� i�!� a�� ca4�� �
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THIS APPLICANT IS: ❑ OWNER �CONTR.ACTOR
PROPERTY OWNER/ NAME:
TENANT ADDRESS: CITY STATE ZIP
PHONE:
CONTRACTOR NAME: G�'� .,S/ /,%��f � u�sA���/i� i/.���
SUBMIT A COPY OF �
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER EXP:
AND CERTIFICATE OF ADDRESS: �� �S - L�/ G �//1/ �' CITY G��-�'i'�j � STA�E�%LiP S��
INSURANCE PHONE —(Ei �` Y�.S� FAX "�'i E—
PROPERTY TYPE � SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDI1'ION ❑ GARAGE/SHED ❑ WINDOWS
�BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK � SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR MODELING
DESCRIBE WORK BEING DONE: p/,� 'J—'G ,�' /L"v� -�.o✓jyJ
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT�
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: O DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOF'FIT/FASCIA �DITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? 0 YES ❑ NO I. 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 OYes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALLTE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE ST'ICKER 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•
'OTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Chazge
Total Due
USINnG THE 1997 U.B.0 FEE SCHEDULE) .
OCCUPANCY TYPE
$ 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 ( )
$ 12'd" �� 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
confotmance 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 per it 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 b�e ' �view and approval o�f� p�la�ns. / /`
SIGNATURE OF APPLICANT��--- �°" PRINT NAIv"y������E" lr�CyCC"�%6ATE ,���/�
APPROVAL INSPECTOR SIGNATU ' �