P - 35215Building BUILDING Permit No.� L I�
Inspections RESIDENTIAL APPLICATION Receivect By: '
763-572-3604 CITY OF FRIDLEY Date
763-502-4977 FA� �� '� �'�) � Q 2
EFFECTIVE 1-1-2011
DATE 1/j , � I �.�1' � I YOUR E-MA,IL ADDRESS �_,�� �� �G'� I�� r�S'�'���ii •��
SITEADDRESS �nb� � ASh� r101"�'7�j St NE, '1i�1c1_ I� �__ `Li.% SS' �„�
,� --
THIS APPLICANT IS: ❑ OWNER CONTRACTOR
PROPER'i'Y OWNERf NAME:
TENANT ADDRESS: �� ITWG��� �q'�LY'1 S7' �I E CITY�IG��'J�J STATE ZIP �-
PHONE: 1/S i o� �((� —�) S�J �
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE #� ^� �r%7 LEAD CERT NUMBER
YOUR STATE LICENSE � � �G,�
AND CERTIFICATE OF ADDRESS:�I �jGI3 1'i7G ;� .4l- Nti CITY ,� t I�. I'�`J STATF�i% ZIg�
INSURANCE PHONE � FAX —% • �
PROPERTY TYPE §�SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STOffiES
PERMIT TYPE ❑ ADDITION ❑ GARAGEJSHED ❑ WINDOWS
❑ BASEMENT FINISH OOF ❑ DRAIN T1LE
❑ DECK SIDING ❑ OTHER
O SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
`L�MAINTENANCE/REPAIR O REMODELING
DESCRIBE WORK BEING DONE: �
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
RO FING �"1 ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES °� �fiOUSE & GARAGE L 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,
❑ Vittyl OSoffit ADDITIONS. & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two seu of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes �No LOCAT[ON 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 COS'f UF LABOR AND MATERIALS:
USING THE 1997 U.B.0 FEE SCNEDULE)
TOTAL JOB VALUATION $%��� � __ 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
$ �/�� 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 (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ 1 n_ Make checks navable to: Citv of Fridlev Attac
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 nd codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an applicatio o a per t work is not to start without a permit on site; that the work will be in cor ance with the
approved plan in the case o ork e review and approval of plans /
SIGNATURE OF APPLICAN PRINT NAME���'�� �� DATE (
ADDO(l\/Ai IUCDC(`T(li? Cif_ i
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