P - 36791B��ilding BUILDING P�rmlt No.�r �5' �
Inspections RESIDENTIAL APPLICATION Received By: � `
z
763-572-3604 �
�63-soz-49�� F� CITY OF FRIDLEY ���°�:
EFFECTIVE 1-1-2011
DATE �`I I") � YOUR E-MAIL ADDRESS J e re m i/ P9 � M a°1'+w� Q � . G� h'1
SITEADDRESS V'7IG�' ��ViY�1� �rv N� `�
THIS APPL[CANT IS: f�OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: �C?'^�MV'! f,/ '-J� � �. �
TENANT ADDRESS: �lO I�Y�e D�v CITY ��f � STATEH}i✓ZIP�
PHONE: !�� � St%� "O�g / H �venMj 61Z 4"50f �13� (G, ��e
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: CITY STATE ZtP
INSURANCE PHONE FAX
PROPERTY TYPE j�SWGLE FAMILY/NEW CONSTRUCTION S[ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES�_
PERMIT TYPE � ADD►TION O GARAGE/SHED � WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK � SIDING JID OTHER p��� )��Y ht N
❑ SWIMMING POOL !� CX
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADD[TION
❑ MAINTENANCE/REPAIR � REMODELING
DESCRIBE WORK BEING DONE: W V a dDY � Y'�r Lv�t � 1 �+E' ��I r��
SIZE OF IMPROVEMENT LENGTH WIDTH �� HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES O HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
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:
IS DING 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
[N 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:
�Q,�,,(,H,$ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ �. l . 2'�
$ 5� .�'m'�
$ �$ �9-a
$ -
$ .�_ _ _�.
� �
See Back Page for Fee Schedule �� gGDa'�
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft + 6 ft = ft x$25= $
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks navable to: Citv of Fridlev Attach
THI-rfS 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 c d of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an apptication for a rmit and w rk 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 w r q' s review and approval of plans. ,) L � g � �(�O
SIGNATURE OF APPLICANT PRINT NAME �� /'1�Q'� DATE
APPROVAL INSPECTOR SIGNAT
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