P - 50481Building BUILDING Permit No.
Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY vate x�f�':D M AY 0
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE �'�-- � Z YOUR E-MAIL ADDRESS �u- ��.QC � Tl L��2-S ��16. �v►.t�."�-l'Cs-� �►•-� .�s
SITE ADDRESS
THIS APPLICANT IS: ❑ OWNER ONTRACTOR
PROPERTY OWNER/ NAME: �'� ti.l�k
TENANT ADDRESS: �% 3 1` ��.,. rv� p Y.y CITY STATE ZIP
PHONE:
CONTRACTOR NAME: � i v�.e_ �2S-C� ��'r h.Trtre7�.v� q� 1tiC -
SUBMIT A COPY OF STATE LICENSE # 3 Z� �'`( S�j LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: J�I IC9 • 1"�i�Y� �v K•✓ �.. � CITY,� I7 1'+�r .�G. STATE 1'Y��iZIP 5 S`t y Z
INSURANCE PHONE �j 3`� S J �� I FAX lo'�'l �i 5 R� 2�
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMTT TYPE 0 ADDITION ,C� GARAGEJSHED ❑ WINDOWS
❑ BASEMENT FINISH i�E'ROOF ❑ DRAIN TILE
❑ DECR ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION � ADDITION
MAINTENANCE/REPAIR r'ib'� ❑ REMODELING
DESCRIBE WORK BEING DONE: (l� YI� 0�
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING s� ❑ HOUSE ONLY
NUMBER OF SQUARES !�� '�iOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARQ.GE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? O 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 LOCAT[ON 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 VALUATlON,1NCLUDING THE COST OF LABUR ANll MA"1'EK1AL5:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surchazge
Surchazge
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 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 pavable to: City of Fridley Attach
TH1S 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 Constxuction 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�l�j w�or�wh'c� rG�iew and approval of pl s. � ��^�,Z
SIGNATURE OF APPLICANT �y � PRINT NAME a�Cv��/_ !�0 L��� DATE
e nnnn�� � r n.roncn�rnn or�wi ��rr ron �-
1�