P - 48444Building BUILDING Pe��t No.�.�`� ��� � I
Inspections RESIDENTIAL APPLICATION �'��
�,�� �� � ; ,
763-572-3604 CITY OF FRIDLEY Date Rec'd: ���� �� �'��
763-502-4977 FAX EFFEC�nvE i-i-2o�z
DATE l Z`� '�� Z YOUR E-MAIL ADDRESS C C�C�i�'"� S U� �' ���� _ (�
stTEaDD�ss �n� 1 1 2� S�
THIS APPLICANT IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NAME: 1' 1� ^N 5 i N y
TENANT ADDRESS: C� O 1 � Z�/ S'� CITY , c.' c� I STATE 'M� ZIP
PHONE: �� SI " 3� �S ' S�� i��
CONTRACTOR NAME:� C( C(,�,J S 1/L v � i � v�
SUBMIT A COPY OF STATE LICENSE #_ �C)�j "��j'Z, �} (p LEAD CERT NUMBER EXP:
YOUR STATE LICENSE
AND CERTIFICATE OF ADDRESS: �(� u� Mt"72 �.z"�Sa�- /')/' CITY Gc /�� ��� STATB/�, ZIP13`YZ 2
INSURANCE pHONE ��2 ' 3%C — �/Z (,, FAX �
PROPERTY TYPE �FAIGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � ADDITION ❑ GARAGE/SHED [$�-INDOWS
❑ BASEMENT FINISH ❑ ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE: � �.cr....,..� �- �- CJ i�,t
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT SQ FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT
I. 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,
� V�nY� ❑Sofrit SID1NG/SOFFIT/FASCIA ADDITIONS. & PORCHES SUBMIT
❑ Aluminum ❑ Trim REMOVED? ❑ YES ❑ NO 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS c/ 3. Energy Calculations
IN EXISTING OPENINGS �es ❑No qCATION OF WI�VDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF �u.. F- �ril �� Uti�'-� MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES & t
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION �`��G 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
$ ���1 � `.�—
$ z,�;
$ �; U `
$
See Back Page for Fee Schedule
65% of Building Permit Fee
.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 for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach Sti
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 e }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 all�;vor h�i requires review and approval of p
SIGNATURE OF APPLICANT - PRINT NAME �T ,' '�I�,.sr.� DATE Z' z`� '� Z
APPROVAL INSPECTOR SIGNATURE