P - 48459Building BUILDING Pe��t No.:�`d���a�
Tiispections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY ��e�
763-502-4977 FAX EFFECTIVE 1-1-2010
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DATE YOUR E-MAIL ADDRESS �'= �1G��c c� W'b': t t" C �t�"�
SiTE ADDxESS ri''6�6 f%n 1 v�rcr� Sf �IC--
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: iA � �t+` �
TENANT ADDRESS: �1�C7 �rf G'�a ��' CITY �� � STATE %�:v� ZIP
PHONE:
CONTRACTOR NAME: �� �'l fP +�--
SUBMIT A COPY OF STATE LICENSE #��� `� �Q C� EXP DATE �.:�! !�� ��
YOUR STATE LICENSE ,�
AND CERTIFICATE OF ADDRESS: 'i�� C��-� � CITY t' � TATE�IP �•rU
INSURANCE pHONE � � "� � � "� � � � FAX
PROPERTY TYPE �SINGLE FAMILYMEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUC7TON STORIES
PERMIT TYPE ❑ ADDt7'ION ❑ 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: C'�6 'i�-r-�.5 �
SIZE OF IMPROVEMENT � LENGTH WIDTH HEIGHT S FT
ROOFINC p HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUM$ER OF SQUARES ❑ HOUSE & GARAGE �. Existing Floor Plan
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
' FOR NEW CONSTRUCTION INCLUDING DECKS,
SIDIlVG � ADDITIONS. & PORCHES SUBMIT:
❑ Vinyl ❑Soffit
❑ Aluminum ❑ Trim 1. Sete Plan/Swrvey showing the existing structures
O Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ONo 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 VALUA'1'1UN,INCLUlltIVt� 1 H� l;u�r ur i,aisux ai�L ivi,� i r,nit�►i,a:
°� (USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ c+�� •�% 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
$ (/�Gj:as See Back Page for Fee Schedule
$ � 65% of Building Permit Fee
$ .001 times the total job valuation
$ 0 .0005 x Permit Valuation Minimum $.50
$ $5.00 (State Licensed Residential Contractors)
$ $2100 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$24=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ , Make checks payable to: City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
lations
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 applicatio r a perm' and wor is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of ork w' quir eview and approval of plans.
SIGNATURE OF APPLICANT ' PRINT NAME -��A �. �°�-� � [�tCi�r�_ DATE � �'J� °'p�
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