P - 83516Building BUILDING permit ivo.:
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY ���e'�:eA�? R 1��� �2
763-502-4977 FAX EFFECTTVE i-�-ZOiz
DATE ��I�C I L ��, � � I� YOUR E-MAIL ADDRESS oJ � or� /> � S-I �� Q a I� C D/h
si� anDxESS �.S�a i—�Y,�. �S7- rtJ� F/,'t � L E�, SS ya I �
THIS APPLICANT IS: OWNER OCONTRACTOR
PROPERTY OWNER/ NAME: �/ D%%l'1f / f�/YI PS� rlJ
TENANT ADDRESS: 7 sa �- vZ y� S% /v� CITY �%1 /�i �-� � STATE%1'IIII ZIP SS a�
PHONE: ��P � SD�'77Dl�, �H� �(p 3 a (O �?4 0 � �� 3 8n?- �7
CONTRACTOR NAME:
SUBMIT A COPY OF STATE LICENSE # LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: CITY STATE ZIP
INSURANCE PHONE FAX
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES /
PERMIT TYPE � ADDITION ❑ GARAGE/SHED ❑ WINDOWS
ASEMENT FINISH O ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: O NEW HOME CONSTRUCTION O ADDITION
❑ MAINTENANCE/REPAIR MODELING
� . . ., „ .
DESCRIBE WORK BEING DONE:, �
SIZE OF IMPROVEMENT s LENGTH °� 8 R K'� WIDTH / � C(`� HEIGHT S� � S FT (�
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
1. 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,
❑ Vinyl ❑Soffit SIDING/SOF'FIT/FASCIA �DITIONS. & PORCHES SUBMIT:
� Aluminum ❑ Trim REMOVED? � YES ❑ NO L Site Plan/Survey showing the existing structures
� 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 VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
USjNG THE 1997 U.B.0 FEE SCHEDULE)
JOB VALUATION �. �'�1° OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surchazge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ 3 See Back Page for Fee Schedule
$ " 65% of Building Permit Fee
$ .� O .001 times the total job valuation
$ .0005 x Permit Valuation Minimum or .50
$ $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC far determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ . `� Make checks oavable to: Citv of Fridlev Attacl
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 perrti t 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 h'c re � res review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME O4�vJ I E-� ✓►1 i�10�"DATE �-� 3�� � ��
APPROVAL INSPECTOR SIGNATURE
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