P - 42836Building BUILDING Permit No.: �� �� i�
Inspections RESIDENTIAL APPLICATION Received By:
763-572-3604 CITY OF FRIDLEY Date�'�t: �„�� �,� ��
763-502-4977 FAX EFFECTivE �-i-zoi� �'������
DATE / 'V" I I ' I � YOUR E-MAIL ADDRESS � �J ^ � � � C'i ,r'� . L,� +�t
SITE ADDRESS � � � �� �� � � �(. L�. � �r''i 1 �- �/ . i�'G��/ � � �.3 � r
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ NAME: 6 r vvc,� l� h��' ..
TENANT ADDRESS: ��� 7S ,7 / f--�' � � �.-L.� �CITY �✓` � � �.t. ' STATE N'� ZIP S S
PHONE: 60%— � ��� �7���
CONTRACTOR NAME: EX � d r
SUBMIT A COPY OF �V � � �� �� LEAD CERT NUMBER /v �T'� I Q 7 / � � ' �
YOUR STATE LICENSE STATE LICEN5E # ,
AND CERTIFICATE OF ADDRESS: � ��j �„ �__?�. v� � Ji t12 . � - CITY_��� ���STATE�"fNZIP .j ,�y
INSURANCE pHONE --- lj S — S u 3 t�s FAX ��� q^� Z S�
PROPERTY TYPE �INGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ,,�(ROOF ❑ DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCElREPAIR ❑ MODELING
DESCRIBE WORK BEING DONE: �A�--� l� t»
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING "�( ❑ HOUSE ONLY
NUMBER OF SQUARES ✓/ ❑ HOUSE & GARAGE BASEMENT REMODELING SUBMIT:
l. 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,
❑ Viny] ❑Soffit ADDITIONS_ & PORCHES SUBMIT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing structures
❑ Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS FOR WINDOWS – PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCKIBE SIZE OF MANUFACTURE 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:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ 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
$
$ ub��
$
$
$
$
$
$
$
$ i �,
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 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
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the infortnation 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 a permit 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 of all or wh�ch requires review and approval of pla s. p /
SIGNATURE OF APPLICANT � PRINT NAME ��*i L7f�-�.t-+'L DATE ���I—" � 1
APPROVAL INSPECTOR SIGNATU —�
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, ELECTRICAL AND MECHAIVICAL WORK