P - 44838��
� � (Q t2S
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE [ b I �
SITE ADDRE5S _
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-20] 1 �
YOUR E-MAIL ADDRESS I 1 �lX� l�
n �..
❑ OWNER ONTRACTOR
NAME: 1Y�-C.`� � %�I.
ADDRESS: � n CITY /'1�
PHONE: � lU� "' S� a" �� I� l0
NAME: lil�'� �-��.�-(�1C_
STATE LICENSE # riC�� O � � LEAD CERT
PHONE ( a' , �'�J �' b tJ FAX (� I d" CT �
SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH OOF ❑ DRAIN TILE
❑ DECK IDING ❑ OTHER
SWIMMING POOL
�W HOME CONSTRUCTION ❑ ADDITION
�MAINTENANCE AIR ❑ REMODELING
.. �eGc✓ O d- re,otU.c•e da Sa c�G�,►�S
Permit No.: �(U�rUO�"f1�
Received By: '
Dat�e�: '� � , '�
t1Cl. U
m�e�ur,2►Y�c _ ccr�
5TATE IIN�IP_��
�7 �t�-S �- -1
STAT�ZIP � 1�
� 1���
��
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NiJMBER OF SQUARE5 ❑ HOUSE & GARAGE 1. Existing Floor Plan
GARAGE5 ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FORNEW CONSTRUCTION INCLUDING DECKS,
Vinyl ❑Soffit ADDITIONS, & PORCHES SUBMIT:
Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structeues
❑ 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-VALLJE AND
OR FOR I*TEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUM$ER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLIJDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ I O OCCUPANCY TYPE
Percnit Fee $ � a�. See Back Page for Fee Schedule
Plan Review $ _ 65% of Building Pernut Fee
Fire Surcharge $ �, � .001 times the total job valuation
Surcharge $ .0005 x Pernut Valuation Minimum $5.00
License Surcharge $ $5.00 (State Licensed Residential Contractors)
SAC Charge $ $2230 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft + 6 ft = ft x$25= $
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Deternuned by Engineering
Sewer Main Charge $ Agreement necessary () Non Necessary ()
Total Due $ r%„i�\�. TL S Make checks uavable to: Citv of Fridlev Attach Stipularions
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pernut and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of t e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
pernut but only an application for a permit an � ork is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of�o�� c v�' r i ,aj�� pproval of p��r�, , M,,�l )/ _�l � �� j(4 /
SIGNATURE OF APPLICANT r� v i��RINT NAME WY � 7 /�-�'� DATE 6� I
APPROVAL INSPECTOR SIGNATURE � _ O