P - 48480Bui�ding BUILDING Permit No. �l a a�
Inspections RESIDENTIAL APPLICATION Re
763-572-3604 ITY F FRIDLEY vate��'� ��o
763-502-4977 FAX C �
EFFECTIVE 7-1-2010
DATE YOUR E-MAIL A DRES L� G V� l� %l% I r� r�I �! L�' //7 y i C 0
SIT'E ADDRESS '' � a �-C �- v'fi� 1`- �� � �
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR �
PROPERTY OWNER/ NAME: � �• � V' � I Y�)G L
TENANT AnDRESS: �� I i��C �� �- i� Y�Y`l- �1 STa� ir �N�S'"2
PHONE: Ic,� , �O�' �� o��
CONTRACTOR NAME:/� � �.E' %�QG � �q
SUBMIT A COPY OF STATE LICENSE # � Cl � EXP D `3 -3 I- 2 0�a
YOUR STATE LICENSE � �7
AND CERTIFICATE OF ADDRESS: �'��°� � �'�� �/� " CITY lldYl STAT��� ZIP�
INSURANCE PHONE� — , � � FAX � 1!�'3` -7 Cl S`O �5
PROPERTY TYPE l� SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDIT'ION ❑ GARAGE/SHED WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: �EV�b1.0 CK��� t/Ly � IYl:�a� �1 �vll tti/ �L'✓ 3- I VLS ��I p C (�✓
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ 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: ❑ 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
❑ 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-VALUE 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 BASL�� UN VALUAI�IUN� 1NCLUDIN(G'1'HL�' CUS'1' UN' LAI3UK AlVll MA1L� KlALa:
/- (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $(!/S(i�Z� OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ � �i?� ZS
$
$
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2100 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks uavable 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 e� that the work will be in accordance with the
approved plan in the case of all w ' quire •.iew and proval cyf plans. �
SIGNATURE OF APPLICAN i^ PRINT N ME � L�� 1��.�{��%DATE I v
APPROVAL INSPECTOR SIGNATURE � l,E-r�..���5� /`L 7 L t v
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