P - 42278Building � BUILDING pe�it No::� � l��� ���
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Inspections RESIDENTIAL APPLICATION Received By: �
763-572-3604 CITY OF FRIDLEY DatR�c1
763-502-4977 FAX EFFECTIVE 8-14-04 �
DATE � ^� D YOUR E-MA[L ADDRESS
SITE ADDRESS �� �7 f^ /�/' �
THIS APPLICANT IS: ❑ OWNER �iCONTRACTOR
PROPERTY OWNER/ NAME: /�KJ Z /i /
TENANT ADDRESS: ��'�� CITY ��i Id� STAT6/iM�'�2iP�
PHONE: �' P
CONTRACTOR '
NAME: 77�A f+..d.�l A..s....s I�G
SUBMIT A COPY OF ,o"�''�o"
YOUR STATE LICENSE STATE LICENSE # EXP DATE ����� /
AND CERTIFICATE OF ADDRESS: /7R�1\ jL77 �iCTT CTTY STATE ZIP
INSURANCE T��vr
PHONE FAX
PROPERTY TYPE INGLE FAMILY/NEW CONSTRUCTION S�[ZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGFJSHED ❑ WINQOWS
❑ BASEMENT FINISH ❑ ROOF O DRAIN T1LE
❑ DECK ' ❑ SIDING �-0THER ���
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑MAItdTENANCElREPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
!
__ _.
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY
NUMBER OF SQUARES ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
l. ExistingFloor 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,
O Vinyl ❑Soffit ADDITIONS_ & PORCHES SUBMI7:
O Aluminum ❑ Trim 1• Site Plan/Survey showing the existing strvctures
and proposed project.
❑ Other ❑ Fascia — 2. Two sets of consuuction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS OYes ONo LOCATION OF WINDOWS FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF MANUFACTURE STICKER ON WTNDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF W[NDOWS
ALL FEES ARE BASED ON VALUATlON, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION S/ m�D � OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
__$ �;j (J •`" See 8ack Page for Fee Schedule
$ 65% of Building Permit Fee
$ a .001 times the total job valuation
$ ' .0005 x Permit Valuation Minimum $.50
$ $5.00 (State Licensed Residential Contractors)
$ $2000 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$22=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agre�ment necessary ( ) Non Necessary ( )
$ . . Make checks �avable to: �'itv of Fridlev Attach
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 a pe it and work is not to start without a rmit on s'te; that the work will be in accordance with the
approved plan in the case of ich re ires review and approval of pl
SIGNATURE OF APPLICANT PRINT NAME ,�� W�'� DATE ����'/�