P - 48623Building BUILDING Permit No.: ��
Inspections RESIDENTIAL APPLICATION Rece' �v
763-572-3604 CITY OF FRIDLEY Date ec cY:
763-502-4977 FAX EFFECI'IVE 1-1-2012
DATE � "� �t% I °t YOUR E-MAIL ADDRESS •�1' `N��� � �'• � 4 / )t- G o � S � � y , COrn
SITE ADDRESS ��� � � � �
THIS APPLICANT IS: ❑ OWNER ❑CONTRACTOR
PROPERTY OWNER/ NAME: ��U o c n r� ,A
TENANT ADDRESS: Iv � � CITY F� �'J STATE /"/�ZIP � 3iZ
PHONE: �* ' J � o — SS �
CONTRACTOR NAME 1� r w r C�h+ ' 1
SUBMIT A COPY OF STATE LICENSE # �- �� Ci oL LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICAT'E OF ADDRESS: � 5��- CITY J STATE�IP f � J
INSURANCE PHONE �� `� 3�- st FAX
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDI'ITON O GARAGFJSHED ❑ WINDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING 0 OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR MODELING
DESCRIBE WORK BEING DONE: �L �✓1 D�t— C�� ° d- a �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING O HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARg1GE 3. List of structural members to be used
PROPOSED HEIGHT: r-..
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit SIDING/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMOVED? � YES ❑ NO I. Site Plan/Survey showing the e�sting 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:
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
(USING THE 1997 U.B.0 FEE SCHEDULE)
� OCCUP.
$
$ ;�
$
$ 5'7�
$
$
$
$
$ � t � L!
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the tota.l 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
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 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 �tl-�vork w�h}' � requires review and approval of p is. /' �j �%..�^f'� \
SIGNANREOF APPLICANT�� � l// PRINTNAME Ni: + I DATE �/��rX�O�n��