P - 44206Building BUILDING Perrnit No.: C.�� �'��"`' ����'�'
Inspections RESIDENTIAL APPLICATION Received By: �'��'�
763-572-3604 CITY OF FRIDLEY vat��'�:�C`�' 1��o�
763-502-4977 FAX EFFECTIVE 1-1-2010
DATE r d �� Z� �� YOUR E-MAIL ADDRESS � m / G,ft � �S�•r C''�'.yl
SITE ADDRESS lp � �� � Q � //Z �G �� ��-
THIS APPLICANT IS: OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: �i'rrn �5 / G/�{i�2 �S p
TENANT ADDRESS: L►� �7I S�G� /i7 � /.7/1 N�- CITY ��L / JJ L�%� STATE ��LI� �S
PHONE: %�� 2Z�P7�1��
CONTRACTOR Nq�;
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE �! EXP DATE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE pHONE FAX
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
O TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF O DRAIN TILE
❑ DECK SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
0 MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ��S p HOUSE ONLY $pSEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGES 0 ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structurat 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
yVINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPEIVINGS-DESCRIBE SIZE OF MANUFACNRE STICKER ON WINDOW.
OPENIIdG 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
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$
$
$
$ �
$
$
$
$
$
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.50
$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 aavable to: Citv of Fridlev 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 wip 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 al,�ork whic qu' es r ew and approval of plans. /j
A.n�s4l' ��� DATE �� �� av/o
SIGNATURE OF APPLICANT �--' PRINT NAME �
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