P - 42145Building BUILDING permit r1o.:d6 65
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY t��f� ��
763-502-4977 FAX �� ���
EFFECTIVE 1-1-201I
DATE Z i YOUR �MAIL ADDRESS 1 G� �'G � D '�O
SITEADDRESS 5 .� ' �n S� /1/�v j � /Yf
THIS APPLICANT IS: OWNER �CONTRACTOR
PROPERTY OWNER/ NAt�: �
TENANT' twv�ss: ��3 .Zne+- .S�—/1%f/ ci� �tdIGN sTn zlr Sf
rxort�: G3 50 � 77 �8
CONTRACTOR N,�:
SUBNIIT A COPY OF
YOUR STATE LICENSE STnTE LICENSE # LEAD CERT 1vUMBER
AND CERTIFICATE OF ADDRESS: CITY STATE Z[P
1NSURANCE PHONE FAX
PROPERTY TYPE TNGLE PAMILY/NEW CONSTRUCTION SIZE
0 TWO FAMILYlNEW COI3STRUC'S'ION STOKI�
PERMIT TYPE ❑ ADDTIION 0 GARAGFISHED [1 WINDOWS
❑ BASIIvIDVT FINISH �ROOF ❑ DRAIN TII.E
❑ DECK ❑ SIDING ❑ 01HF,lt
❑ SWIlVIlvIDVG POOL
E OF WORK: ❑ NEW HOME CONSTRLJCTtON L7 ADDITION
MAINTFddANCElREPA1R ❑ REMdDELING
DFSCRIBE WORK BEING DONE: G i O
SIZE OF IMPROVII�NC LENGTH Z WIDTH Z HEIGHT FT O
FING ❑ HOUSE ONLY � fj
NUMBER OF SQUARES _� ❑ HOUSE & GARAGE ���' �-FMnn -�n`?� St�RMIT:
GARAGES ❑ ATTACHED GARAGE D h 2_ �� ��
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structu�al memb�s W be used
PROPOSED HIIGHT:
SIDING FOR NEW CONSTRUCTiON It3CLUDING DECKS,
� Vinyl �Soffit ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Sutvey slqwing the e�stiog structuns
❑ Other ❑ Fascia � � �°�'
2. Two sets of ca�dvdion pl�s
wnvnows 3. Fnergy Calculati�s
IN EXISTINC� OPENINGS OYes �No LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPIIVINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLID NUMBFdt OF WINDOWS
ALL FEES ARE BASED ON VALUA'iZON, INCLUDiNG THE COST OF LABOR AND MATERiALS:
(iTSING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb C�t Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
$ ��� (J See Back Page for Fee Schedule
$ 65% of Building P�tnit Fee
$ .001 tunes the total job valuation
$ .0005 x Permit Valuation Minimum 55.00
$ $5.� (State Licensed Residential Contractors)
$ $2230 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Detennined bY Engineerin8
$ Agreement necessary ( ) Non N�essary ( )
$ . Make c�ecks a�vsble to: Citv of Fridtev Attncb
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCFSSED
I hereby apply for a building pernut and I acimowl�ge that the information above is complete and accurate; d�at the work will be in
conformance with the ordinances and codes of the City of Fridley and wiffi the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work is not to start without a per�nit on site; that the work will be in accordance with the
approved plan in the case of ork w' uire � ew and approval of pi�s
SIGNATURE OF APPLICANT PRIN7' NAME �//� H� I C ���'GDATE Y JS
APPROVAL INSPECTOR SIGNATURE —T
i�i F1�C� NfYTR• CFPA12 A PFRMi'f`C A)3F itRCliTiitFil FC1R Pi ITMRiN(: �i F("CRiChi: ARlLI AARf''ifiANtflAl Wfl1tY