P - 42376Building
Inspections
763-572-3604
763-502-4977 FAX
DATE ,Q �
SI'I'E ADDRESS "'�
THIS APPLICANT IS:
PR�PERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICEN5E
AND CERTIFICATE OF
INSITRANCE
PROPERTY TYPE
PERMIT TYPE
BUILDING
RESIDENTiAL APPLICATION
CITY OF FRIDLEY
Ex�EC�rtvE i-i-2oio
YOUR E-MAIL ADDRESS _
L � � , lu G
❑ OWNER ONTRACTOR
NAME: � � `'� �
ADDRESS: 'r'� � �• �`C
PAONE� � � ��; l ` � o( lf�
NAME: ��L
STA1'E LtCENSE # `
ADDRESS:��,Q v�. � -
PHONE `A � tX- � ��^ �- � �1 � O
�3 SINGLE FAMILY/NEW CONSTRUCTION
C�! TWfl FAMiLY/NEW CANSTRUCTION
C1 ADDITION �GARAGE/SHED
❑ BASEMENT FINISH ROOF
❑ DECK '`,�` SIDIN
❑ SWIMMING POOL
Permit No.;�, L i � -i�(;�-%�'
;� '
Received By: _�
�
Date�'�{i: - 1
u
CITY �'C'� a��G
EXP DATE �=_
CI11' �
FAX 1 � •
S1ZE
STORIES
0 WINDOWS
❑ DRAIN TILE
❑ OTHER
TYPE OF WORK: O NEW HOME CONSTRUCTION ❑ ADDITTON
AINTENANCE/REPAIR ❑ REMODELiNG
DESCRIBE WORK BEING DONE: � R ['afs�u R �►-� I�C� SI�I
SIZE OF IMPROVEMENT LENGTH WIDTH
ROOFING � � OUSE ONLY
NUMBER OF SQUARES i � 0 HOUSE & GARAGE
��`i
G S ' ❑ ATTACHED GARAGE
PROPOSED ❑ DETACHED GARAGE
PROPOSED HEIGHT:
STATE_(��ZIP
STATI�_ �`.►ZIP����
�
' I r4M.r• �i�ir��p �c.ee�/��
HEIGHT SO FT
BASEMENT REMODELING SUBMTT:
1. Existing Fioor Plan
2. Proposed floor plan
3. List of structural members to be used
S FOR NEW CONSTRUC'IION INCLUDING DECKS,
v�y� oi-� S� �-TV ❑sot�t ADDTTI023S. & PORCHES Si3BMIT:
❑ Aluminum ��\ ❑ Trim 1. Site Plan/Swvey showing the existing structures
❑ pther �='I ) ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOW5 3. Energy Calculations
IP3 EXISiTNG OPENINGS OYes �No I.00ATION OF WINDOWS FOR WINDOWS – PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANCJFACTURE 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:
(US THE 1997 U.B.0 FEE SCHEDULE)
COTAL JOB VAL'UATION � - '�" .-�I `.��' _ _ 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
$ .,
�?.-�_ �`�
$
$ :�I�'
$ /` (>�
$ r_ji�.%=
$
�
$
$
See Back Page for Fee Schedule
65% of Building Pernut Fee
.001 times the total job valuation
.0005 x Pemut Valuation Minimum $.50
$5.00 (State Licensed Residential Contractors)
$2100 per SAC Unit {Plans to MWCC for determination)
ft+6ft= ftx$24=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
THIS IS AN APPLICATTON FOI2 A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building pemut and I acknowledge that the inforcnation above is complete and accurate; that ttre work will be in
conforniance with the ordinances and codes of fihe City of Fridley and with the Minnesota Constiuction Codes; that I understand this is not a
permit but only an application for a permit and work is not to start without a pemut on site; that the work will be in accordance with the
approved plan in the case of all� which requires review and approval of plans. �
SIGNATURE OF APPLICANT 7�1� L. _.-- -- _PRINT NAME �l ::rN'�E�i.. �`,--t`':= :�iC...�� DATE ���; ��1�'!1
N(1'f'F• C�.PAR ATR PF.RMITC ARF. RRf1TtiRRT1 FnR PT .iTh�fRiNf� FT .Ff'TRT!`AT . ANTi MR!'H ANTt`AT . WnRK