P - 48250Building BUILDING Permit No.: ' C�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY vate Rec'd:
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE L / 3 �� I �--� YOUR �MAIL ADDRESS -�-�\ � � a � � �,f'N4.Jt � � � G O �
SITE AD SRED S_ S$ �( � c�-S [�-�� h_._s�'�-�� .S -F- N�
THIS APPLICANT IS: ❑ OWNER OCONTRACTOR
PROPERTY OWNER/ �,�: �/ „�,�,,r-,'1,`,� (a .�� -r-l—
TENANT ,�DRESS: S$'o ( W a-S Ia�� 6h. S �� CITY� •I►` STATE�ZIP
PHONE:�_— � — W ID S� I� Z- �.� ` / Z..B �
CONTRACTOR N,�:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CTI'Y STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERNIIT TYPE ❑ �DITION ❑ GARAGF/SHED ❑ WINDOWS
�I,BASEMENT FINISH ❑ ROOF ❑ DRAIN TII,E
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIlvIIvIING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCITON � ADDTI'ION
❑ MAINTENANCF/REPAIR �REMODELING
DESCRIBE WORK BEING DONE: f�1 �, o •e.. tw-a`1f 1�`O'�"N"'�
SIZE OF IMPROVEMENT � �• LENGTH WIDTH HEIGHT S FT
FING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE &c GARAGE
1. Existing Floor Plan
GARAGE5 � ATTACHED GARAGE 2. Proposed $oor plan
PROPOSED SIZE: O DETACHED GARAGE 3. List of structutal members to be used
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
❑ Viayl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim REMO'VED? O YES 17 NO 1. Site PlanlSurvey showing the existing structures
❑ Other ❑ Fascia � P�P�d ProJ�
2. Two sets of consdvction pian
WINDOWS 3. Energy Calcutatio�
IN EXISTING OPENINGS OYes ONo LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VAI,UE AND
OR FOR NEW OPENINGS=DESCRIBE SIZE OF MANUFAC'T[JRE STICKElt ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATI�N, INCLiJDING THE COST OF LABOR AND MATERIALS:
�I7SING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION S�l� -�" OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb G�t Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ Z. � See Baek Page for Fee Schedule
$ 65% of Building Penni# Fee
$ .001 times the total job valuation
$ .Up05-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 ( )
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCE3SED
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 pernut 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 1 ork w'ch uires re iew pprpval of p s. , /
SIGNATURE OF APPLICANT � � PRINT NAME, L� /1���DATE F 2� 2.-=
APPROVAL INSPECTOR SIGNATURE
� . , �
' PLEASE NOTE: SEPARATE PERMITS ARE REOUIItED'FOR PLUMBING, ELECTRiCAL AND MECHANICAL WORK
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