P - 84309Building BUILDING Permit No. I
Inspections RESIDENTIAL APPLICATION Received By��
�63-s�2-3604 CITY OF FRIDLEY D �� � �
763-502-4977 FAX � � � � �
EFFECTIVE i-1-2012
DATE d� .S— '�� YOUR E-MAIL ADDRESS
sITE ADDRESS 3� hV '� w i� /L%,L—
THIS APPLICANT IS: OWNER ❑CONTRACTOR
PROPERTY OWNER/ NpME: �vy, N e�
TENANT ADDRESS: � � l' � � ��I �1+� � �C�1T � r .�� sTATE .vztP -5���2
PHON$�/t ` �� J ' I ' � / ,3cy
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICAT'E OF ADDRESS: CITY STATE ZIP
INSURANCE pH E FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION []�ARAGE/SHED ❑ WINDOWS
O BASEMENT FINISH �IROOF ❑ DRAIN TILE
� DECK �C� SIDING ❑ OTHER
❑ SWIMMINGPOOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCT'ION O ADDIT'ION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: .t1 � � S�fN G^C
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING /12 ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES - J ;p�HOUSE & GARAGE 1. Existing Floor P(an
GARAGES • ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GAR�IGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT:
� Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 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 BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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 ��15
$
$ c'
$
$
$
$
$
$
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 ( )
Make checks aavable to: Citv 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 applicatio or 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 ork w jr�`s view and approval of plaJ�' v � tU' ��� `�
SIGNATURE OF APPLICANT i PRINT NAME (��'''/ /LiVt� �" DATE `
APPROVAL INSPECTOR SI ANRE °