P - 44207Building BUILDING Permit No.;�,�'t;"d,�-.�, ��' 1+'�
Inspections RESIDENTIAL APPLICATION Received By:�'�
763-572-3604 CITY OF FRIDLEY Dat �
763-502-4977 FAX EFFECTIVE 1-1-2010 ��� ' �
DA'CE R E-MAIL ADDRESS �t J f� 6�,��1�7 U/ l�, //() l'�
SITE ADDRESS
THIS APPLICANT IS: OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: �
TENANT ADDRESS� � �_ Q�.,�T_CTTY �--�i � STAT&�(�c7ZIP���
PHONE:°E ��d e�1�c�( ��(L—
CONTRA.CTOR NAME:
SUBMIT A COPY OF STATE LICENSE # EXP DATE
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE �SINGLE FAMILY/NEW CONSTRUCTION SIZE
TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUC7'ION ❑ ADDITION
❑ MAINTENANCFJREPAIR O REMODELING
DESCRIBE WORK BEING DONE: !� D(I f Y�1�i
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
R F <_ p HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARESJ` � ❑ HOUSE & GARAGE
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structurai members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
O Vinyl ❑Soffit ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim i• Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOW� 3. Energy Calculations
IN EXISTING OPENINGS OYes CINo 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 1NSTALLED NUMBER OF WINDOWS
ALLN�1�:1:5AK1�:13A1�llV1V VALUA11V1V�11V(rLUllllVli IHEC:VJI Ul� LAKVKAIVLMA1L�KlAL.�:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALU
Permit Fee
Plan Review
Fire Surcharge
Surchazge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$ �
$
$
$
$
$ , _
ANCY
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $.SQ
$5.00 (State Licensed Residential Contractors)
$2100 per SAC Unit (Plans to MWCC for determination}
ft+6ft= 8x$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks payable to: Cityo uf Fridle_y
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
Attach
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 d codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicati 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 o ork wh' h i es revi an approval of plans.
SIGNATURE OF APPLICAN PRINT NAME� � Pq, r�% � WL! j�(�L�DATE ,�_�� ` l�