P - 40005� � �-o � 3
Building BUILDING Permit No.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY �l�� 2 6 2 11
763-502-4977 FAX EFFECTIVE 1-1-201 ]
DATE �� I� YOUR&MAILADDRESS �4��C-' a �"ll��C�. i'►'�0.'1 �C:(1YYl
SITEADDRESS �J�����,y�11�SGi1�Y'' �� �'Y''���`�-V� 1►t'YL �J����
THIS APPLICANT IS: �B'OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: {'yac Lok 1,.r
TENANT ADDRESS:Jg�% jQ{nNISG'7i 1JT' h'� CITY �^� STATE{i�%1� ZIP Ij`�T-�Z
PHONE: �i,;j 1..iQ� q ���
CONTRACTOR NAME:
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # LEAD CERT NUMBER
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE pHONE FAX
PROPERTY TYPE ,,0'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 CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR �'1FEMODELING
DESCRIBEWORKBEINGDONE: #^���S111V�� 0.Y`t ef �a.seme. �or r��
SIZE OF IMPROVEMENT LENGTH � �� � WIDTH i � ��� HEIGHT � S FT 9q r�' N
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ 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:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit
ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim I. Site Plac�/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:
�j,�� (�J�ING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $:x 7(�J � 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
`����
1
tit��7
See Back Page for Fee Schedule
65% of Building Pernut 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 MVJCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks pavable 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 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 application for a per t nd work is no to start without a permit on site; that the work will be in accordance with the
approved plan in the case 1 work w ic �rire revie a d approval ns. /
SIGNATURE OF APPLICANT PRINT NAME DATE /
APPROVAL INSPECTOR SIGNA ;� i�—'�
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