P - 45836Building BUILDING Permit lvo.: ����
Inspections RESIDENTIAL APPLICATION Received By:�__
763-572-3604 CITY OF F�DLEY Da�'d'� � � �' � � � ��
763-502-4977 FAX EFFECrivE �-�-zo>>
DATE � l- � YOUR E-MAIL ADDRESS
SITEADDRESS � �� ��� d' • �� ^ T
THIS APPLICANT IS: ❑ OWNER ❑CONTRACTOR �
PROPERTY OWNER/ NpME: /A�,.
TENANT ADDRESS: �•i � � ��'� rCs� CITY STATE � IP
PHONE:
CONTRACTOR NAME: °" `"
SUBMIT A COPY OF STATE LICENSE #������ �; � LEAD CERT NUMBER
YOUR STATE LICENSE
AND C�ERTIFICATE OF ADDRESS: �O'� �' Y�'�'�.�lfdat.. ��+l� L�,,, CITY �Yl��'O�l STATE �ZIP�
INSURANCE pHONE ��D " FAX �1+� -' �'16CYI
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZB
❑ 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 ❑ REMODELING
DESCRIBE WORK BEING DONE: %Yi �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOiJSE ONLY BASEMENI' REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE �, Existing Floor Plan
GARAGES ❑ ATTACHF,D GARAGE 2. Proposcd floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural mcmbcrs to bc uscd
PROPOSED HEIGHT:
SIDING � FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1• Sitc Plan/Survcy showing the cxisting structures
❑ Othcr ❑ Fascia and proposcd projcct.
2. Two sets of construction plans
WINDOWS 3. Encrgy Calculations
TN EXISTING OPENINGS 'I�Ycs � 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 AR� BAS�ll ON VALUA'1'lUN 1NCLUUING'lHr: CUJ1' UN' LA13UK A1Vll 1VIAIEKIALJ:
�
t� (U��1 �TI�� 1�7 U.B.0 FEE SCHEDULE)
TOT�L JOB VALUATION $ 1� �` �� � �� OCCUPANCY
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
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 $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Flans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks aavable to: City of Fridley Attach
THIS tS AN APPLICATION FOR A PF,RMiT-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 wark is not to start without a permit on site; that the work will be in accordance with the
a roved lan in the case qw� w�� ���i�'es review and a roval of ns. Il ^f
SIpGNATU E OF APPLICA�t/� Oo� ����'� PR NT NAME�_�Y� ��+,�-t/Y DA-['E� �VTI I
APPROVAL INSPECTOR SIGNATURE
PLEASE NOTE: SEPARATE PERMITS ARE REOUIRED FOR PLUMBING, ELECTRICAL AND MECHANICAL WORK