P - 44943Building � BUILDING Perrnit Ivo.:'�� � �` ��`� �
Inspections RESIDENTIAL APPLICATION Re�� � �
763-572-3604 CITY OF FRIDLEY Date Rec'd:
763-502-4977 FAX EFFECTIVE 1-1-2010
DATE II �3 YOUR E-MAIL ADDRESS
SITE ADDRESS S�� /GLGE G���,�LVD.
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: Tryy� 7o�to�,
TENANT ADDRESS: S�Sd /�� G�7r,iC � �I � _�3
,gLl�• CIT'Y �I/ STATE ZIP ..S�S Z
PHONE:
CONTRACTOR NAME: Co
SUBMIT A COPY OF STATE LICENSE #�i/i EXP DATE � 3/ �/
YOUR STATE LTCENSE
AND CERTIFICATE OF ADDRESS: 'Z701 — 36� AutF. S. CITY /�ALl , STATE�ZIP�G�
INSURANCE PHONE I Z' )— FAX 6IL^ 3 I'%iL
PROPERTY TYPE O SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT T'YPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �9 ROOF ❑ DRAIN TILE
❑ DECK �SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
'� MAINTENANCE/REPAIR ❑ REMODELING
DESCR[BE WORK BEING DONE:
SIZEOF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING r p HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES �y sa- �#� �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:
FOR NEW CONSTRUCTION INCLUDING DECKS,
❑�� Z'•SSQ � ❑Soffit ADDITIONS_ � PORCHES SUBMIT:
❑ Aluminum ..��� ��� �� ❑ Trim 1• Site Plan/Survey showing the existing structures
and proposed project.
� Other L�wQ� ❑ Fascia 2. Two sets of construction plans
WWDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACNRE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUAT10N,1NCLUDING "1'HE COS"1' Ul+ LABVR ANll MA'1'�;KlALS:
(USING THE 199� U.BI.� FEE SCHEDULE)
JOB VALUATION S•'� ��i, � S�� • �D 4 OCCUPANCY TYPE
Permet Fee
Plan Review
Fire Surchazge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ '
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fec
.001 times the total job valuation
.00DS x Permit Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$2100 per SAC Unit (Plans to MWCC for determination)
$+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined 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
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work wi(I 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 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 all hich re i s review and approval of plans.
SIGNATURE OF APPLICANT � PRINT NAME� DATE _